Can They Really Do
That?
Top 5 Questions Posed to the
Health Systems Committee
• #1 – Can insurance plans have different fee
schedules for different types of providers?
• #2 – Can insurance plans sell my participating
provider contract without my notification?
• #3 – Can insurance plans outsource or exclude me
from performing certain procedures allowed by my
scope of practice?
Top 5 Questions Posed to the
Health Systems Committee
• #4 – Can insurance plans ask for money back on
previous paid claims, and if you don’t comply, can
they take money out of a future claim payment?
• #5 – How can I fight back?
Strategy Basics
• Research the issue – understand the scope of the
problem and avoid jumping to conclusions
• Determine your legal rights with regard to the issue
• Working with the plan – develop a strategy that
appeals to what plans care about
• Communicate with the correct people at the plan
• If you escalate to policymakers, cast the issue in
terms of public policy
#1 – Different Fee Schedules?
The Basics: What Law Applies and Who
Regulates the Plan?
59.3
60
50
40
30
Government
Direct Purchase
27.8
Not Covered
Employer Based
20
10
0
15.3
9.1
#1 – Can Insurance Plans Have Different
Fee Schedules for Different Types of
Providers?
• Applicable Laws
– Medicaid – State/Federal
– Medicare – Federal
– Military – Federal
– Direct Purchase – State
– Uninsured – State
#1 – Different Fee Schedules?
• Employer Plans –
ERISA
– Insured are
regulated by state
and federal law – if it
is in the insurance
code, it probably
applies
– Self-insured are
regulated by federal
law
100%
80%
55
60%
40%
20%
Self
Insured
Insured
45
0%
1st Qtr
#1 – Different Fee Schedules?
• What to Know and Do About Employer Sponsored
Plans
– In firms with 5,000 or more employees, 89% of
workers were covered by self-insured
arrangements in 2006
– Does the insurance card have the employer logo?
– Call the plan administrator
– Always pre-certify your patients so you know the
“paying" field
#1 – Different Fee Schedules?
• What If I Don’t Like the Fee Schedule?
– Renegotiate your contract
– See chapter 2 in the Private Insurance Resource
Guide (PIRG)
– Evaluate your current office profit/loss ratio for the
particular insurance plan
• Survive without it
• Need it to survive
#2 – “Sell” My Contract ?
• Yes, look at the original contract for language such
as “deemed” provider or the definition of payer
• Very common if you signed up with multiple PPO
contracts in the late 80s or early 90s that have
merged over the years (Ex. Multiplan)
• A review of your state laws may be help
#3 - Exclude Me from Certain
Procedures?
• Review your contract thoroughly
– Example: Orthonet
• Definition of experimental or investigational
– Insurance plans typically exclude coverage for
services that are “experimental, investigational
and/or unproven.”
– Confusion sometimes arises because plans may
be imprecise in how they categorize denials
based on such exclusions.
• Within the range of covered services, private plans
typically cover only items and services that are
medically necessary and appropriate.
#4 - Ask for Money Back?
• Review the insurance company’s specific claim that
states you owe them money – if not, ask for
additional information.
• Review your contract to see what your rights are for
these type of claims
– Did they reserve the right to do recoupments?
– Do they have the right to offset the amount
against future payments?
– Is there an appeal mechanism specified, and if
so, does it include timelines?
#4 - Ask for Money Back?
• Recoupment Reasons
– Overpayment
– Retroactive denial
– Individual was not eligible
– Service was not covered
– Miscoordination of benefits – it was subsequently
determined that another payer was responsible
#4 - Ask for Money Back?
• More Recoupment Reasons
– If the recoupment is due to the beneficiary not
being “eligible” for coverage, you can bill the
beneficiary.
– If the recoupment is the result of a payer
coordination issue, is it timely enough that you
can receive the funds from the other payer?
– Does the recoupment affect the amount you
should have received as patient cost sharing?
#4 - Ask for Money Back?
• If there is an available appeal process, file an
appeal
– Write a detailed appeal letter about the claim in
question.
– Cite any contractual provisions and laws that you
believe are violated by the recoupment.
– If the recoupment changes the amount you
should have collected in cost sharing, note your
intent to collect the additional funds.
#4 - Ask for Money Back?
• Appeal Process – continued
– Call the plan and ask to discuss the issue with
either the head of claims or provider relations.
– Using a multi-pronged approach to increase the
chances that your concerns will reach someone
who cares and someone in a position to address
the situation.
– Keep records of your correspondence and the
people you talk to.
#4 - Ask for Money Back?
• Applicable laws regulating recoupments
– Determine what law is applicable (e.g., federal,
state, program-specific law).
– Laws regarding retroactive denials and other
recoupments are frequently found in the section
of the state code that sets forth prompt-payment
laws, laws concerning unfair (or fair) insurance
practices, or claims settlement rules.
#5 - How Can I Fight Back?
• Review chapters of PIRG regarding appeals
process-different for ERISA vs. Non-ERISA plans
• Review and know your state laws - Chapter 9
• Review and utilize sample letters - Chapter 12
Visit http://www.apma.org/privateguide
#5 - How Can I Fight Back?
• Contact the agency in charge of enforcing the
relevant law if no agreement is reached
– Provide concise facts regarding the issue
– Provide history of your efforts to resolve it
– To the extent possible, cast the issue in terms of
public policy
#5 - How Can I Fight Back?
• Issues commonly addressed by the law
– Prohibition on retroactive denials for
preauthorized services
– Timelines for recoupments or retroactive denials
– The information that a health plan must furnish if
it requests a recoupment
– Whether an offset is allowed and/or whether an
appeal must be allowed
– In general, if the applicable law offers more
protection than appears in the contract, the law
will apply
#5 - How Can I Fight Back?
• Sponsor Legislation
– In 2009, APMA’s State Advocacy Committee and Health
Systems Committee initiated the Model Law Project to
protect podiatric physicians and surgeons from
discriminatory and unreasonable practices by payers.
– Next Model Law Project: Retroactive Recoupment Model
Law
– This model law is intended to address deficiencies in state
law that allow payers to recoup payment in an
unreasonable manner.
– A model retroactive recoupment law will be available later
this.
Model Legislation
• Model Fee Parity Project
– Section One: Understanding Fee
Discrimination Laws.
– Section Two: Obtaining Enforcement of
Existing Law
– Section Three: Introducing Fee Parity
Legislation
– Section Four: Resources for State Advocates
– Available at: www.apma.org/modellaws
Model Legislation
• Model Anti-Fee Discrimination and Fee
Parity Act
– Payment may be based on several factors
including market power, geographic location,
or need to include a physician specialty
– Model Law prohibits fee discrimination when
the difference in amount of payment is based
solely on the fact that the physician is a DPM
rather than an MD or DO.
Questions?