More and more we are seeing insurance companies require pre authorization for chiropractic services that in years past did NOT require such. If the doctor is out of network, then many companies will require pre authorization in order to make collecting insurance payment more difficult and force the doctor to consider going in network with the insurance company.
Many Billing Services have experienced going through the hoops, making the call and ordering the Care Notification in full compliance with the insurance plan requirements and STILL do not received the full payments due. Here is an example:
United Health Care. Most of our providers are out of network with United Health Care because the payment fee schedule is so much better than if the doctor is in network, and this is even after the higher copays and deductibles.
We are running into more and more plans that will state the insurance verification thus: If you get your Care Notification prior to providing the services, the insurance plan will cover 70% of the eligible expenses. IF you do NOT get the required Care Notification, then your insurance coverage will drop to 50% of the allowed eligible expenses.
I have talked with many Chiropractic Offices and Billing Services who tell me that they do not even bother to get the required Pre Authorization or Care Notification. They do not want to be bothered with the extra administrative details. However, they are also letting the insurance companies get away with keeping 10% to 20% of each claim. Depending on how much the doctor bills, that can be worth $10.00 per claim, and when you multiply that by how many doctors are out of network, you can bet the extra fee adds up to a tidy sum of the DOCTOR's money - money that the insurance company is keeping.
Since it is the Billing Service's job to get the absolute highest pay for the doctor, one always takes that extra step and gets the required Care Notification.
This entails reporting the diagnosis codes, plus stating how long we need treatment, how many sessions are required, and lastly, exactly what codes will be billed.
Well now, how does ANYONE know exactly what treatment is necessary on the first visit? How do we know how well the patient will respond to any type of treatment?
So, to cover our bases, we report the diagnosis codes, and then we ask for the time allotment that covers until the end of the year (or whenever the plan benefits expire). We then request the exact number of session covered that year by the plan. If they allow what we ask for, then I will not have to call them back this year for a fresh Care Notification (Pre Authorization).
Some case managers will only allow a fraction of what we ask for, and we all know why that is: So the Billing Service or Doctor's Office will be required to take this extra step more than once this year. Again, hoping to discourage us from going though the hoops necessary for getting that extra 20% that is our due.
The Billing Service goes through these hoops, and even after being in full compliance of the Pre Authorization/Care Notification requirements, the claims will INVARIABLY come back paying only the 50%!
Here is how to handle it: Call the insurance company, speak with the representative in India, and send the claim back to be processed correctly. Then, in about four weeks we receive a form letter from UHC stating that the claims were processed correctly and no further payment is due.
Next step is to appeal on paper. This means: paper, ink, time preparing the appeal, envelope, stamp, frustration and having to spend money on a massage (Or a drink). Sometimes the appeal works, and sometimes it doesn't.
We have spent months appealing for such claims, going back and forth ad infinitum, with no real results. Our last recourse is to send the whole thing to the Insurance Commission.
Our new modis operandi is to skip the step where we call our friendly insurance representative in India and simply go straight for the appeal on paper.
This Billing Service stands upon Principle, and if the claim is worth as little as $10.00, if we are in the right, we take these situations all the way to the Insurance Commission.
Sometimes it pays, sometimes it doesn't. The point here is that the insurance company counts on the doctor and his staff to NOT follow up on these situations, and thus they will realize a higher profit margin, AT THE EXPENSE OF THE DOCTOR.
It is bad business for the insurance companies to require pre authoriztion to begin with, and it is double bad business to make the doctor fight for monies due AFTER the doctor has complied with all of their little nit picky requirements.
EVERY Billing Service and EVERY doctor in the US of A should be appealing all the way up to the state Insurance Commission on all such claims. Otherwise, the insurance companies will not only continue to demand pre authorizations, but will tighten the rules and regulations even more.
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