Medical Billing Forum

Payments => Insurance Payments => Topic started by: platmedrec1 on November 24, 2010, 10:45:35 AM

Title: Incorrect Insurance Verifications
Post by: platmedrec1 on November 24, 2010, 10:45:35 AM
I work with a chiro and we do IVs on every patient.  Recently we have had two that when the claims processed are not even in the ballpark with what we were quoted and thus quoted the patient.

1. We called 10/08/10 and were given 2009 plan benefits because her plan started over 9/15/10.  Pt was mad at us because we quoted from these benefits that she would be resp for 20% and now she has a balance that she wasn't prepared for.

2. We called 10/2/10 and were quoted no deductible and $15 copay per visit, and when I called today because her claims are going to deductible, I was told her benefits are $300 deductible 80/20 up to $1k - not even close to what we were told.

We realize that benefits quoted are not a guarantee and we also have a disclaimer on our financial policy that basically we are only as good as the info presented by their ins and ultimately it is the pt resp to know their benefits, yada yada.  But that doesn't help us from looking like idiots that can't do our jobs and it doesn't keep the patient from having a huge balance.  We provide the IV to the pt so they have info to make their tx choices, but getting wrong info from the payer is driving us crazy.  Do we have any recourse?  I did speak with a supervisor on both occasions, but got a sorry 'bout your luck attitude.

Has anyone else ever had this issue and do you have any suggestions?

Cara
Title: Re: Incorrect Insurance Verifications
Post by: DMK on November 24, 2010, 11:18:10 AM
I have had this happen many times.  Chiropractic is treated differently than a standard medical visit by many insurance companies.  ALL you can do is write down what was quoted, or if you check online, print the page.  And tell the patient exactly what the insurance company tells you "benefits quoted are not a guarantee of payment".

Also, be aware that in network and out of network benefits are usually vastly different.

Ultimately, the patient is responsible to know their benefits.  If their policy changes mid-year, they should be aware of that.
Title: Re: Incorrect Insurance Verifications
Post by: Sportsmom on November 25, 2010, 07:49:43 PM
I print out the benefits right off NaviNet and share with the client. When you call the ins they don't understand chrio benefits. I get it a lot from BC/BS of NJ.
Title: Re: Incorrect Insurance Verifications
Post by: midwifebiller on December 02, 2010, 05:09:23 PM
This happens to us frequently. When we call and verify benefits, we fill out a VOB form (our own), complete with the date, time of call, and the name of the rep we spoke with, along with all of the qustions we ask. If claims come back processed not as we were quoted, we send an appeal letter and attach a copy of the completed VOB form. 90% of the time, the claims are reprocessed correctly.

If an appeal is not successful, we ask the member to take the completed VOB form to their HR department--that usually results in claims reprocessing correctly.

~Kelli
Title: Re: Incorrect Insurance Verifications
Post by: PMRNC on December 04, 2010, 09:38:16 AM
Quote
This happens to us frequently. When we call and verify benefits, we fill out a VOB form (our own), complete with the date, time of call, and the name of the rep we spoke with, along with all of the qustions we ask. If claims come back processed not as we were quoted, we send an appeal letter and attach a copy of the completed VOB form. 90% of the time, the claims are reprocessed correctly.

If an appeal is not successful, we ask the member to take the completed VOB form to their HR department--that usually results in claims reprocessing correctly.

Hi Kelli, I am curious..what types of appeals are these? I just ask because (please don't take this wrong) I find it hard to believe you can successfully appeal 90% of verifications processed differently than quoted  ??? ???
Title: Re: Incorrect Insurance Verifications
Post by: midwifebiller on February 12, 2011, 11:29:00 AM
Oops, missed this one. Sorry, Linda--I wasn't ignoring you!

Our providers are out-of-network, so they are not bound by any contract.  The appeal goes something like this:

We are in receipt of your denial for services rendered to [member's name] for reason of: provider type not covered. We request an appeal of this decision based on the following:

On [date and time], we called your office and spoke with [their reps name], who clearly stated midwifery care is a covered benefit under Mrs. [name]'s plan.  A written record of this conversation is enclosed. It was with this information that Mrs. [name] chose to continue care with us. It was with this information that we submitted claims in good faith and did not bill your member for that portion of our care.  We have rendered quality care, submitted claims per your specifications and have done everything necessary to ensure claims are processed for payment.  We expect you to honor your agreement with your member, Mrs. [name], by covering our services at the stated rate. 
Please reprocess the claims for payment.

Most of the time, this is all it takes to get the claims to reporcess. Occasionally they will come back and tell us the rep mis-quoted benefits, and they are so sorry, but midwives are still not covered.  We then send a second letter and have done three-way phone calls with the member and a supervisor at the insurance company to listen to the recording of our initial phone call where benefits were verified.  We hold them to the benefits quoted and have only been unsuccessful once or twice.