Autism Speaks Presentation
October 21, 2011
Today’s Presentation
MedClaims Liaison Overview
• Our mission
• What we do
• Who we are
• How we work
Helping Families Access Insurance Reimbursement for
Autism-Related Therapies
• Common Insurance Pitfalls
• Know the Codes
• Questions to Ask the Insurance Company
• Understand the Limitations of the Insurance Policy
• Authorization, Adjudication, Appeal
MedClaims Liaison
Overview
Our Mission
“It all started with a friend in need…. “
MedClaims Liaison was launched in 2009. Our goal is to deliver
relief, reassurance, and reimbursements to our customers through
comprehensive management of their health insurance claims.
Relief:
• A complete, end-to-end solution for the work of interpreting,
organizing, submitting, auditing, and pursuing claims.
• Single resource for the management of all claims.
Reassurance:
• Confidence that an expert is handling your claims.
• Confidence that your out-of-pocket costs are being properly
accounted for.
• Confidence that you’re getting all you deserve from your coverage.
Reimbursement: • Full and timely compensation from carriers.
Who We Are
We are a team of passionate specialists who advocate on behalf of its
Members to maximize healthcare benefits and minimize stress.
Our claims specialists bring a range of skills to bear when
managing claims on behalf of our customers
Professional Backgrounds
Skill Sets
• Claims processing units of major
health insurance carriers
• Claims processing
• Third party claims processors
• Benefits administration
• Third party administrators
• HIPAA
• Medical offices
• Customer service!
• Medical billing
What We Do
We provide a single resource for the management of the full
lifecycle of our customers’ claims
• Document organization
• Advising customers re. balances due
• Submission of new claims
• Reviewing bills for accuracy
• Auditing and pursuing existing claims
• Negotiating with providers to
reduce balances
• Coordination of
secondary/supplemental policies
• Coordination of HSAs and FSAs
• Filing and pursuing appeals
• Annual statements summarizing
insurance utilization
• Understanding plan options upon
renewals
• Phone and online support
How We Work
(continued)
Get started in 10 minutes.
We start working immediately.
We contact your healthcare providers and
insurance carriers, obtain your historical
bills and claims, and ensure you’ve been
properly billed and reimbursed.
You get all the money back that you
are entitled to!
Helping Families Access
Insurance Reimbursement for
Autism-Related Therapies
Common Insurance Pitfalls
•
“Unclean Claims” get sucked into the insurance black-hole. Make
sure the claim being submitted has all of the necessary elements to
be processed before being submitted.
1. Service provider’s name, credentials, license #
2. Service provider address and phone number
3. Provider Tax ID and/or NPI
4. Itemized dates of service
5. Fees for services
6. CPT codes with corresponding units
7. Diagnosis codes
8. Patient Name
9. Bill/Receipt total
10. Indication of payment in full (if applicable)
Common Insurance Pitfalls
(continued)
I have the benefits!
I have a “Clean” claim to submit!
I mailed my claims to
the correct address!
What do you mean my claims aren’t
on file and they aren’t anywhere in
the system??
Common Insurance Pitfalls
(continued)
Do’s and Don’ts of Insurance Customer Service:
 DO: Ask the customer service agent to document everything that was
discussed during your phone call
 DO: Ask for the customer service agent’s name and reference # for the
phone call – document the date of the call
 DON’T: Be afraid to ask difficult questions about the coverage of your plan
 DO: Trust your instincts – if you feel like the customer service agent was
giving you wrong information, call back and ask to verify the information
 DON’T: Assume anything about your plan or benefits
 DON’T: Send documents via certified mail to a PO Box!
 DO: Follow up periodically to ensure that your claims are received and
getting processed
 DON’T: Stop because you’re frustrated! Allowing too much time to pass can
hinder your ability to get the money you’re entitled to!
Know the Codes
In order to ensure that the insurance company is
reimbursing the maximum amount of health care
costs, according to the benefits of the policy, you have
to KNOW THE CODE.
• Make sure that the CPT/HCPC code on the claim matches it’s
description and has been billed with the appropriate unit/time ratio.
• Make sure that the CPT/HCPC code accurately reflect the services
that are being rendered.
• Make sure that you find out which benefit the code is going to use
under the benefits on the policy.
Questions to Ask the Insurance Company
• Is this a Fully-funded Insurance policy or a Self-funded policy? (Also know
as fully-insurance or self-insured
• If Self-funded, then state mandated coverage has to be specifically
stated as applicable.
• If Fully-funded, state mandates are eligible
• Is this a Small Group or Individual Policy?
• If the plan is either small group or an individual policy, state mandated
benefits do not apply unless specified
• Do state and/or federal mandates apply to this policy? (if the Rep sounds
clueless, tell them to check the contract exceptions or certificate of
coverage)
• Are there exclusions for the coverage of Autism related treatments?
• If yes, then claims with an ASD diagnosis will likely deny (299.XX)
• If no, then claims will only receive ASD benefits with an ASD dx
Understand the Limitations of the Policy
• Check visit limits for Speech, Occupational, Physical, Behavioral Therapies
 Are these visit limits separate or combined?
 Are these visit limits separate or combined between the In-Network and
Out-of-Network benefits?
• Ask if authorization is required prior to services being performed.
 If so, is this something that can be performed by the parent or does it
need to come from the provider’s office?
• Check to see if there are Penalties for failure to obtain authorization prior to
services
 If so, what are they?
• Ask what are the Timely Filing Limitations of the policy
 What is timely filing for a Participating Provider claim?
 What is timely filing for a Non-Participating Provider claim?
 Ask if there are there any dollar limitations for a specific benefit?
Authorization, Adjudication, Appeals
Authorizations
• Pre-Certification – Obtained PRIOR to services. Strive for this every
time. It will expedite claims and alleviate requests for medical records.
 If the insurance company states that pre-certification is not required
but that they can request medical records once a claim is submitted,
request that a precertification can be performed.
 You will need to know the codes that are going to be billed. If the
insurance company authorizes for a 96152 but the provider bills a
98960, the claim will deny and this is an appropriate denial.
• Retro-Authorization – Performed after services have been rendered
 This type of authorization is typically done after services have been
performed. The insurance company will request the provider’s medical
records. Follow instructions closely so that potential for errors are
minimized.
Authorization, Adjudication, Appeals
(continued)
Adjudication
There are a variety of ways an insurance company receives and processes
claims. Understanding HOW a claim is processed gives insight when a
claim is mis-processed.
• Auto-Adjudication – Some claims submitted on standardized billing
forms are electronically scanned for Data, entered, and then processed
without a human ever touching the claim. Claims that are submitted
electronically through a provider billing service are also often autoadjudicated.
• Vendor Processing – Often times, some insurance companies will
receive claims and then outsource their claim processing to a vendor
or workshop. Actual claims representatives will process the claim .
• Manual Processing – Claims are entered by claim and benefit analysts
who manually enter the claim and benefit data.
Authorization, Adjudication, Appeals
(continued)
Appeals Tips
When it comes to filing an appeal, insurance companies will all have their own
internal process. When a claim is denied , and there is recourse to Appeal, the
instructions outlined on the Explanation of Benefits have to be followed
CLOSELY. There are typically stringent time frames for a customer to respond.
 Do not send an Appeal via FedEx or Certified Mail unless a physical address is
available
 Make sure that to include appropriate documentation and supportive
evidence to “make a case” to the insurance company
 Do not give up because the insurance company has upheld the denial.
Typically there are 2 or 3 levels of appeal that can be filed.
 If an insurance company continues to uphold a denial and all internal Appeal
options have been exhausted, the next step is to contact your state
Department of Insurance . They can provide direction on what the next steps
are for filing a Grievance, a 3rd Party Review or other options available.
Our Commitment to This
Community
Contact Information
Jacqueline Eckert
Director, Reimbursement Solutions
jeckert@medclaimsliaison.com
(484)493-7771 or 1(855) MCL-4YOU
www.medclaimsliaison.com