Effective Strategies for Dealing with Denied Insurance Claims

1. How to deal with insurance carrier for a denied or mishandled claim ---by Ling Zheng, L.Ac.

2. ATCMS Seminar on March 14, 2010

3. What Do You Need to Do Before Sending Your Bill to Insurance Company?

4. To verify your patient’s acupuncture benefits before treating for your patient. • 2. To treat for your patient. • 3. To complete a CMS-1500 claim form and send it to insurance company within 45 days from the date of service.

5. I. What may happen after your claim has been submitted ?

6. Insurance company must process your medical reimbursement within 45 days, according to New York State insurance laws. You may complain to New York State Insurance Department at website: www.ins.state.ny.us.gov, or at phone number: (800) 358-9260, in case insurance company fails to process your reimbursement on time.

7. Insurance company may contact you via mail, fax or telephone to require for any additional information regarding your reimbursement processing. But they should not have held your reimbursement or ignore it.

8. You may receive a letter from insurance company to require for additional information, if insurance company has any questions regarding your claim.

9. Usually, the required information may include patient’s information (such as date of accident, cause of the injury, previous medical history, etc.); provider’s information (such as your professional status, tax ID number, or form W-2, etc.); and/or medical document(s) (such as medical necessity letter, initial physical examination report, daily progress notes, re-evaluation report, etc.).

10. This is your professional responsibility to provider those required information within 45 days. Otherwise, your claim may be denied.

11. II. To understand your claim Statement

12. When you receive the payment with a claim statement, you may be very happy and exciting for your successful reimbursement. I would like to remind you to take a few minutes to review the statement carefully and make sure that you have got payment completely as you expect. Otherwise, the reimbursement process has not been done successfully.

13. You must know how to read the statement and be able to find out the part of your reimbursement cut by insurance carrier. If you disagree with insurance carrier about the decision, you need to start your next action to get back the cut part of reimbursement from the insurance carrier.

14. Insurance carrier recognizes that many providers don’t want to spend their time to review the claim statement carefully and fight for the unreasonable decision make by insurance carrier. They make “mistakes” for saving their medical expenses.

15. To estimate the $ amount you may get payment from insurance carrier and your patient’s responsibility: • Insurance Co must pay you: • A = (B – C) X D • Your pt’s responsibility: • E = C + (B – C) X F

16. A is the $ amount insurance carrier must pay for your medical claim; B is the total amount you bill to insurance company; C is the patient’s deductible which the patient needs to pay for meeting the required amount.;

17. D is the percentage of the insurance plan will cover for the procedure(s), according to the insurance policy; E is the patient’s responsibility; F is percentage that patient needs to share for the co-insurance as the policy.

18. For example, you totally bill $1,270 to insurance company for the patient’s services (including evaluation and acupuncture) fee. The patient’s calendar year deductible is $200 for participating provider and $500 for non-participating provider, and the patient has paid $380 for the deductible during the calendar year. The plan will cover 90% for the services provided by participating provider and 70% for non-participating provider, according to the policy.

19. If you are a non-participating provider, B = $1270, C = 500 – 380 = $120, D = 70%, F = 30%. Insurance company must pay you: A = (1270 – 120) X 70% = 805 ($) The patient’s responsibility: E = 120 + (1270 – 120) X 30% = 465 ($)

20. If you are a participating provider, B = $1270, C = $0.00 ($200 deductible has been met), D = 90%, F = 10%. insurance company must pay you: A = (1270 – 0) X 90% = 1143 ($) The patient’s responsibility: E = 0 + (1270 – 0) X 10% = 127 ($)

21. 2. To understand a claim statement: You need to read the claim statement , and check the payment for every item. If you get the payment as much as you expect, the reimbursement has been processed successfully!

22. If the payment is less than what you expect, you need to read the explanation on the statement and understand why some of items have not been paid or have been paid partly only.

23. 3. To review your benefits verification report which you made when you contacted with insurance carrier to verify the patient’s eligibility. If you consider the insurance carrier’s determination being acceptable, according to the verification report, accept it.

24. 4. If you disagree with the determination, you may: • call insurance company for • discussion; • (2) write a letter to require for • re-process the claim; • (3) write a letter to appeal.

25. Don’t be sad when your claim is denied by insurance company. Insurance carriers always try to make some troubles for your medical reimbursement. They try to find out any reasons to deny your reimbursement. They want to make you feel tire to get the payment and finally you may give up it. This is the way to save their medical expenses. It is a game.

26. You have to be patient, know the rule, and have the right tools and enough knowledge to play the game well if you want to win it. When you deal with insurance carrier for a denied claim, you must know why your claim is denied at first.

27. III. Most frequent reasons for the denied claims

28. The policy doesn’t cover for • acupuncture procedure; • The way to prevent: to verify the patient’s coverage benefits and make sure the benefit includes acupuncture, before starting the treatment;

29. 2. The policy covers acupuncture procedure for some particular conditions which do not include the patient’s current condition; The way to prevent: to verify the patient’s acupuncture benefits and make sure the patient’s condition is one of the listed conditions to be treated with acupuncture according to the policy term, before starting the treatment;

30. 3. The policy covers acupuncture procedure provided only by a physician certified acupuncturist. But it doesn’t cover acupuncture provided by a licensed acupuncturist; The way to prevent: to verify the patient’s acupuncture benefits and make sure the benefits will be available for licensed acupuncturist;

31. 4. The policy covers acupuncture procedure, but acupuncture is not a medically necessary procedure for the patient; The way to prevent: to write a medical necessity letter and mail it with your initial claim form to insurance company;

32. 5. You fail to apply for pre-authorization of acupuncture as the policy term; The way to prevent: to verify the patient’s acupuncture benefits including the pre-authorization requirement. To apply for pre-authorization as the policy term;

33. 6. You fail to have an acupuncture referring letter from the patient’s PCP, as the policy term; The way to prevent: to make sure that the referring letter is required or not – through eligibility verification, and require your patient to get one from his/her PCP if it is necessary, before starting the treatment;

34. 7. Exceed in the number of visit or total $ amount coverage for acupuncture limited by the policy term; The way to prevent: to get the coverage information regarding the limitation when you verify the patient’s acupuncture benefits;

35. 8.You keep on treating the patient with acupuncture treatment for long-term, insurance carrier doesn’t understand why you treat your patient endlessly and determine the procedure as “not medically necessary”; The way to prevent: to mail a re-evaluation report to insurance company when you complete a course (such as every 12 or 15 visits) of acupuncture treatment plan and start a new plan continually;

36. 9. You fail to submit your claim within 45 days (or 90 days---depend upon the policy terms made by different insurance companies) from the date of service; The way to prevent: to complete the claim form and submit it to insurance company within 45 days from the date of service.

37. 10. You fill out the claim form with incorrect information, such as CPT codes or ICD-9-CM codes, etc; The way to prevent: to complete the claim form carefully. In case it happens, correct the claim form and re-submit it to insurance company.

38. IV. How to deal with insurance carrier for difficult cases

39. You don’t get any response from insurance company within 30 days after you submit your claim – pay the fees claimed, require for additional information or deny the claim. • I suggest you to call insurance company • to check for your claim status and make sure your claim been received, if you have not received the response after 5 weeks you mailed your claim.

40. If they can’t find out your claim, it may be missing and you have to submit another copy. If the claim has been processed, you need to know the total amount has been paid, check number and issue day, where the check has been mail to, and when you may receive the check

41. A few insurance companies, such as Empire Blue Cross & Blue Shield, may mail the check to patient directly if the services fee is claimed by a non-participating provider, for the case, you have to contact your patient to request for sending the check to you.

42. If your claim has been received by insurance company for a while and still has not been processed, remind them that New York State insurance laws require insurance company to process the claim within 45 days.

43. 2. You are required to submit additional information such as medical document, provider’s information or patient’s information. You have to do it within 45 days as the requirement. It is your professional responsibility. You have no choices except you give up the claim.

44. 3. Your claim has been denied due to the coverage policy and you fail to verify the coverage benefits carefully before starting the treatment. Some insurance companies may have some very unreasonable and unfair acupuncture coverage policies. You may refuse to accept those insurance plans. But you have not enough power to make them change their policies.

45. To fail to verify the eligibility will lead to fail in your reimbursement. It is your mistake and nobody is able to help you. Some insurance policies require a PCP referring or pre-authorization or set a limitation for acupuncture treatment. You have to follow up the policies. There are not solution ways for these denied claims. What you need to do is to prevent it through careful eligibility verification.

46. 4. If you have verified your patient’s acupuncture coverage benefits carefully and followed up the policy, and your claim is still denied due to the information released by the representative is incorrect, you may contact (by either phone call or mail) the insurance carrier to discuss with them and tell them what happened.

47. Insurance company should take the responsibility to solute the problem caused by its employee’s mistake(s) and re-consider for the reimbursement –-- although the policy doesn’t cover for the procedures. To win the game, you need a tool – eligibility verification report indicated the representative name and date/time when you talked with him/her over phone.

48. 5. Sometime, insurance companies may deny your claim due to acupuncture procedure is determined as a “not medically necessary treatment” for the patient, although the patient has acupuncture coverage benefits.

49. You need to submit a medical necessity letter with supporting evidences based medicine (the research reports of Clinical trials in relation to acupuncture treating for the same condition), to insurance company for re-process.

50. You need to search those evidences based medicine from time to time and save the information on you computer. You always need the information for your successful medical reimbursement. This is another tool to win the insurance game.