How to deal with
insurance carrier for a denied
or mishandled claim
---by Ling Zheng, L.Ac.
ATCMS Seminar
on
March 14, 2010
What Do You Need to Do
Before Sending Your
Bill to Insurance
Company?
1.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.
I. What may happen
after your claim has
been submitted ?
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.
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.
You may receive a letter from
insurance company to require
for additional information, if
insurance company has any
questions regarding your
claim.
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.).
This is your professional
responsibility to
provider those required
information within 45
days. Otherwise, your
claim may be denied.
II. To understand
your claim Statement
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.
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.
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.
1. 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
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.;
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.
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.
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 ($)
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 ($)
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!
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.
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.
4. If you disagree with the
determination, you may:
(1) call insurance company for
discussion;
(2) write a letter to require for
re-process the claim;
(3) write a letter to appeal.
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.
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.
III. Most frequent reasons
for the denied claims
1. 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;
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;
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;
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;
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 preauthorization as the policy term;
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;
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;
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;
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.
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.
IV. How to deal with insurance
carrier for difficult cases
1.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.
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
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 nonparticipating provider, for the
case, you have to contact your
patient to request for sending the
check to you.
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.
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.
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.
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.
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.
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.
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.
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.
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.
You must know which conditions are
suitable to be treated with
acupuncture – according to currently
available evidences based medicine.
When you decide to accept your
patient insurance plan and complete
CMS-1500 claim form, you must
consider the patient’s diagnosis and
the supporting scientific evidences.
6. If you recognize that your claim
is denied due to insurance
company’s mistake on the claim
process, just call insurance carrier
(claim department) to point it out
and request for re-process. It will be
easy for solution.
7.If your claim is denied because
you complete the claim form
incorrectly, you need to correct
the original claim form then resubmit it to insurance company
for re-process. You may get
payment. But it will take a little bit
longer.
V. How to appeal
for your
denied reimbursement
As my personal experience, only
60-65% of my claims submitted to
insurance companies are processed
and paid smoothly, although I
always try my best to verify and
patient’s eligibility carefully,
complete CMS-1500 claim form
correctly, and prepare necessary
medical documents completely.
Other 25-30% of my claims are
processed and paid successfully
after dealing with insurance carriers
through the above solution ways, via
phone discussion, mailing or fax the
related information or documents.
About 10% of the claims need to be
appealed when the above efforts fail.
There are three different
levels of insurance appeal:
(1)Internal appeal – Level 1;
(2) Internal appeal – Level 2;
(3) External appeal
It means you have three opportunities
to fight with insurance carrier for its
unfair or unreasonable claim
determination. You may start your
appeal from any level. But I suggest
you to start it from level 1, if you
want to have more opportunities to win
the game.
You must initiate your appeal
within 60 days from the date your
claim is denied, if you want to do
so. You may re-start the next level
of appeal when you have fail on
your previous appeal within 60
days.
To submit your internal appeal
(Level 1 or 2) letter you may find
out the mailing address or fax
number for appeal units of the
insurance company, on the claim
denied letter or statement. You may
call insurance company to get the
contacting information also.
For external appeal, you need to
submit your appeal letter to:
New York State Insurance Dept.,
160 West Broadway
New York, NY 10013-3393,
or visit the website:
www.ins.state.ny.us.gov.
1. To introduce the different
levels of appeal
(1)
Internal appeal – Level 1
The appeal will be processed by
insurance company. As the
requirement of insurance regulation,
insurance company must have a
group of people, usual is known as
“Appeal Units”, to handle insured’s or
provider’s appeal if they disagree with
the claim determination made by claim
department and request for appeal.
The staff of the appeal units
should be different from the
group who processed the
same claim in the claim
department. Internal appeal –
Level 1 is the primary level of
the internal appeals.
(2) Internal appeal – Level 2
This is the second level appeal
processed by insurance company.
It should be handled by the
different team from who reviewed
your Level 1 appeal.
You may require for the
appeal if you disagree with
the determination made for
your Level 1 appeal, if you
have a strong evidences or
information to fight with them.
Of course, you may initiate
the external appeal to New
York State Insurance
Department directly, if you
don’t have other available
evidences or information to
fight with insurance company
on the appeal Level 2.
(3) External appeal
This is a final appeal on government
level. Acupuncturists may fight with
insurance companies when your
medical reimbursements have
been processed unfairly or
reasonably. You may win the case
if you have never given up.
It will be the pressure for
insurance companies, and
will be possible to make
insurance carriers modify
their unfair or
unreasonable policy terms
under the pressure.
2. Key points
regarding appeal letter
l
(1)Basic information regarding
the case: including patient’s
name, birthday, insurance ID
number, claim control
number, and dates of
services.
(2) To consider your view for
the appeal action, through
reviewing the claim statement
and all of records on your
patient’s filer;
(3) To mention why you disagree
with the determination made by
insurance company for your
reimbursement, accordingly.
The following key points may be
useful for different cases on your
appeals:
(a) If your reimbursement was
denied due to someone released
you incorrect information when
you verified the patient’s eligibility,
you need to mention how the
representative of insurance
company mislead you with
incorrect information.
Insurance carrier should have
taken the responsibility for
their employee’s mistakes and
unqualified provider services.
You need to attach an
eligibility verification report
with the appeal letter.
(b) If your reimbursement was
denied due to acupuncture was
determined as a “not medically
necessary procedure” for the
patient’s condition, you need to
identify that acupuncture is a
medically necessary procedure
for the patient’s condition.
To enclose the evidences
based medicine in
relation to acupuncture
treating for the same
condition which you treat
for this patient.
(c) If your reimbursement was
denied due to the insurance
plan covers acupuncture
procedure provided by only
physician certified
acupuncturist, you may
mention that:
With New York State Education and
medical practice Laws, either
licensed acupuncturist or physician
certified acupuncturist is legal and
qualified acupuncture practitioner.
Both of them should have the same
professional rights in the field of
practice acupuncture.
Patients have rights to
choice a legal and qualified
acupuncture practitioner
including either licensed
acupuncturist or physician
certified acupuncturist.
The policy has limited patient’s
rights to choice their acupuncture
practitioner and licensed
acupuncturist’s professional rights
to practice acupuncture. It usurps
the legitimate licensing authority of
the New York State Education
Department and the Board of
Regents.
(4) To request for re-processing
and re-considering for the
denied claim;
(5) To enclose a copy of the
claim statement sent by
insurance company;
(6) Print your name and
professional title, then, sign
on the appeal letter.
VI. Case Study and Discussion
……
Conclusion
When you receive a check
from an insurance company,
don’t be too exciting. You
need sitting down to review
the statement and make sure
the claim has been paid
completely.
If your claim is denied, don’t
be sad. You may find out the
way to get your service fee
back successfully. 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. You have to be
patient, know the rules, and
have the right tools and
enough knowledge to play it
well if you want to win it.
The following Tools You May Need
1.Insurance Benefit Verification Report
Form;
2.The Evidences Based Medicine—
Acupuncture for those Common
Conditions;
3.Medical Documents: Including initial
evaluation report, re-evaluation report,
medical necessity letter, and daily office
notes.
Good Luck!