the process of appealing/filing a grievance for a commercial insurance claim
Post on 03-Jan-2016
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The Process of Appealing/Filing a Grievance for a Commercial
Insurance Claim
Steve Verno
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Disclaimer
I am not a lawyer! I don’t provide legal advice.
This presentation is for training purposes only!
Samples contain NO actual patient information. All names are fictitious!
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NO GUARANTEES!
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We Will NOT Discuss!
• ERISA!• HEALTH INSURANCE CONTRACTING
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What we WILL Discuss!
• Timely Filing Denials• No Authorization/Precertification• Payment Less than Billed Charges• Payment as a Non-participating Provider• Denied as a Non-participating Provider• Payment Sent to a Different Address• Claim is NOT paid or denied• Claim for Alleged Overpayment (Refund)
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• Another Insurance is Primary (Refund)• Patient Never Revealed Medicaid Coverage• Third Party Liability• Information Not Received from Patient• Benefits Expired or Terminated• Seen Prior to Effective Date of Coverage• Bundled Service• Downcoding
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What we WILL Discuss!
• Information Requested from Provider not Received
• Not a covered Service
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What we WILL Discuss!
Timely Filing Denial
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Proof
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STATUTES
• FS 617.6131 AND 627.6131: (3) All claims for payment or overpayment, whether electronic or nonelectronic:
• (a) Are considered received on the date the claim is received by the insurer at its designated claims-receipt location or the date the claim for overpayment is received by the provider at its designated location.
• (b) Must be mailed or electronically transferred to the primary insurer within 6 months after the following have occurred:
• 1. Discharge for inpatient services or the date of service for outpatient services; and
• 2. The provider has been furnished with the correct name and address of the patient’s health insurer.
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THE EOB
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The Patient’s Benefit Manual
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Certified Mail/Return Receipt
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Website
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Provider Contract
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No Authorization or PreCertification
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No Authorization or PreCertification
Proof
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State Law• 641.513 Requirements for providing emergency
services and care.—• (1) In providing for emergency services and care
as a covered service, a health maintenance organization may not:
• (a) Require prior authorization for the receipt of prehospital transport or treatment or for emergency services and care.
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State Law• 641.3156: A health maintenance organization must
pay any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized by a provider empowered by contract with the health maintenance organization to authorize or direct the patient’s utilization of health care services and which was also authorized in accordance with the health maintenance organization’s current and communicated procedures, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization. 21
The Benefit Manual• Your Benefits• Although a specific service may be listed as a covered
benefit, it may not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition.
• Refer to the “Glossary” section for the definition of “medically necessary.”
• Certain services must be precertified by XXXXX (name removed). Your participating provider is responsible for obtaining this approval.
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Website
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Provider Contract
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Payment Less than Billed Charges/Payment as Non-Participating Provider
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Payment Less than Billed Charges/Payment as Non-Participating Provider
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PROOF
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State Law used by HMO
• If a health maintenance organization is liable for services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider.
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The Benefit Manual
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The Benefit Manual
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Denials as a Participating provider
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Denials as a Participating provider
PROOF
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State Law• Each health maintenance contract, certificate, or
member handbook shall state that emergency services and care shall be provided to subscribers in emergency situations not permitting treatment through the health maintenance organization’s providers, without prior notification to and approval of the organization. Not less than 75 percent of the reasonable charges for covered services and supplies shall be paid by the organization, up to the subscriber contract benefit limits.
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The Benefit Manual
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Payment Less than Contracted Amount
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Payment Less than Contracted Amount
PROOF
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The Contract
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Payment Sent to a Different Provider
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Payment Sent to a Different Provider
PROOF
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Check to Correct Address/Claim form
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Claim is Never Paid or Denied
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Run Insurance Aging Reports Weekly
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Verify! Verify! Verify!
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Resubmit PaperClaims to CEO by Certified Mail
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How do you Find the CEO?
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Securities Exchange Commissionwww.sec.gov
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Securities Exchange Commissionwww.sec.gov
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Securities Exchange Commissionwww.sec.gov
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Securities Exchange Commissionwww.sec.gov
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Securities Exchange Commissionwww.sec.gov
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Securities Exchange Commissionwww.sec.gov
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Your State Division of Corporations
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Your State Division of Corporations
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Your State Division of Corporations
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Your State Division of Corporations
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Your State Division of Corporations
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Always Send Certified Mail/Return Receipt
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Keep Track with Tickler File
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Don’t Let Your Claims Die!
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Lets take a short break!
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WELCOME BACK!
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Check Uninsured Accounts for Insurance
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Refund Demand
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Refund Demand
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PROOF
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State Law
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FS 627.6131 and 641.3155
1. All claims for overpayment must be submitted to a provider within 30 months after the payment of the claim.
A provider must pay, deny, or contest the claim for overpayment within 40 days after the receipt of the claim.
The Organization may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health maintenance organization’s overpayment claim as required by this paragraph.
Another Insurance Was Primary
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PROOF
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Your Laws!
• FS 627.6131 & 641.3155• All claims for overpayment must be submitted
to a provider within 30 months after the health insurer’s payment of the claim. A provider must pay, deny, or contest the health insurer’s claim for overpayment within 40 days after the receipt of the claim.
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Insurance Affidavit & Insurance ID Card
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Website Verification
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Burden of Proof is on Them!
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Patient Never Presented Medicaid Coverage
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Proof
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Third Party Liability
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• Letters of Protection
• Subpoena
• Subrogation
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Third Party Liability
Information Requested from Patient & Not Received.
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PROOF
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State Law• Florida Statutes 627.6131 & 641.3155• Notification of the health insurer’s determination of a
contested claim must be accompanied by an itemized list of additional information or documents the insurer can reasonably determine are necessary to process the claim.
• A claim must be paid or denied within 90 days after receipt of the claim. Failure to pay or deny a claim within 120 days after receipt of the claim creates an uncontestable obligation to pay the claim.
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State Law• Florida Statutes 641.3154• If a health maintenance organization is liable for
services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider
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Patients Benefits Were Expired or Terminated
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Proof
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Website Verification
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State Law• FS 641.3154 (1) - If a health maintenance organization is liable for services
rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider.
• FS 641.3156(2) - For purposes of this section, a health maintenance organization is liable for services rendered to an eligible subscriber by a provider if the provider follows the health maintenance organization’s authorization procedures and receives authorization for a covered service for an eligible subscriber, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization.
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Bundling (Service is included in the primary service or theservice is included in a service previously paid)
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PROOF
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NATIONAL CORRECT CODING INITIATIVE (NCCI)
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99213 92531 0
99213 92532 0
99213 93562 1
99213 94002 0
99213 94003 0
COL 1 COL 2 MOD
CPT MANUAL
• Page 4• The actual performance and/or
interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code
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Insurance Contract & Benefit Manual
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Downcoding
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PROOF
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The EOB, Original Claim & Medical Record
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Requested Information Never Received
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PROOF
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State Law
• FS 627.6131 & 641.3155 c)• 1. Notification of the health insurer’s determination
of a contested claim must be accompanied by an itemized list of additional information or documents the insurer can reasonably determine are necessary to process the claim.
• 2. A provider must submit the additional information or documentation, as specified on the itemized list, within 35 days after receipt of the notification. Additional information is considered submitted on the date it is electronically transferred or mailed. The health insurer may not request duplicate documents.
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CERTIFIED MAIL/RETURN RECEIPT
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NOT A COVERED SERVICE
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NOT A COVERED SERVICE
PROOF
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State Law• Florida Statute 627.6405: The Legislature finds
and declares it to be of vital importance that emergency services and care be provided by hospitals and physicians to every person in need of such care
• Florida Statute 641.31: Each health maintenance contract, certificate, or member handbook shall state that emergency services and care shall be provided to subscribers in emergency situations
•
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The Benefit Manual
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The Benefit Manual
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Filing an appeal or grievance
Stick to the facts! Reference their error and your Proof!
Never threaten! Do NOT Wait, respond immediately. Send everything Certified Mail/Return Receipt Allow them time to respond. If no response, file a grievance with
the appropriate regulatory agency!
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File Grievance with Regulatory Agency
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Which One are YOU afraid of?
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Never Give Up! Never Surrender Attitude!
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Questions???
steve_verno@yahoo.com
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Thank You
steve_verno@yahoo.com
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