Resolving Insurance Carrier Issues

What Do You Do When You Aren’t Reimbursed Properly By An Insurance Carrier?

Well we have been faced with that problem for almost a year now.  One of our providers treats many Medicaid patients for addiction to oxycodone.  Some of the patients are enrolled in one particular Medicaid HMO.  It seems to be a popular choice for Medicaid patients as they have the option of about 4.  At least he gets more of that one then he does of any other.

Anyway, we have had continuous problems with this particular company over the years.  Once we actually had to contact our state senator because we couldn’t get the issue resolved.  The provider is a DO (doctor of osteopathy) and he is considered a PCP.  However, when he treats addiction patients he is not there PCP.  But addiction medicine does not require authorizations.  However, since he wasn’t the PCP the insurance carrier was denying all of his claims for no authorization.  It took a while but they finally agreed that we would have to send paper claims to a specific person and they would hand process his claims.

We’ve been doing that for several years and with the exception of a few bumps here and there it’s was going along pretty well.  Until August of 2012.  One day Zack, who handles this account, noticed that they were not paying the normal rate for the office visits anymore.  It wasn’t a huge difference, but it was a few dollars per visit and he sees a ton of patients, so it adds up.  Zack also noticed that were not paying for the urine screens.  Our provider does random urine screens on his addiction patients at his discretion.  If the patient is acting unusual, or he notices physical signs that indicate they may have used drugs, he will test their urine right in the office.  The test kit tests for 12 different types of drugs and the kits are rather expensive.  Plus he has to go thru the process of testing, etc so there are other costs involved.  His staff has to get the sample, run the test, document the results, and then the doctor goes back in to discuss the results.  It’s really a bit more involved than just dipping the urine.

Anyway, Medicare only allows $15 for this test so the doctor actually loses money.  This particular insurance carrier was reimbursing him over $135 for the test, until August of 2012.  Without any notice or explanation they suddenly started denying the tests.  When we contacted them, they really couldn’t give us any explanation.  So we went to our provider rep.  She said she would look into it and get back to us.  Back and forth to everyone in the company we could think of with little results.  Emails, calls, threats – nothing helped.   To make a long story short, 11 months later we have just been given an explanation.

So basically due to IT issues, they haven’t been able to process the claims correctly.  They are now working on an IT fix so that they can reprocess.  This is approximately $50000 that is owed, so it’s a pretty big chunk of change.

But the point is, what do you do when insurance carriers don’t pay what is do?  Well, you start by contacting customer service to see if the issue can be resolved with a simple phone call.  If you don’t get the results you are looking for there then try the provider rep (if there is one).  Usually they can get to the bottom of things.  But if you can’t get any results there either, you still have options.  Each state has some form of agency to handle complaints.  In NY we file a complaint thru the Department of Financial Services.  Filing a complaint is easy and is done online.

Filing a complaint will start an investigation.  Usually that will get things moving, as long as you are in the right.  If they owe the money it is hard for them to justify why they haven’t paid.  Although sometimes they will respond to the complaint with their side of the story which doesn’t always match your perspective of how things went down!  But you will have a chance to respond to their response.

If the insurance carrier is a government plan such as Medicare or Medicaid you can go to your local politician.  For Medicare I would go to your National Congressman for your area.  They can help with Medicare issues.  For Medicaid, your state senator can sometimes help.

The main thing is not to give up.  If you are hitting a brick wall and you know the provider is due the money, keep fighting for it.  Just keep going until you reach someone who can help.  Just think how much money they save because people give up.