General Category > General Questions

Independent Review- Assistance needed (original issue in the 'No Preauth' thread

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PMRNC:
Ok, since not ERISA, you pretty much have exhausted with the State Dept / AG. The Customer service rep's are covered by their disclaimer that " benefits quoted are not a guarantee...etc., etc."  The services are  "NON" Covered as you found out with even the state dept of insurance. At this point, what I would do is bill the patient as there is nothing else you CAN do. In meantime you can let the IRO play out, I would say to cover the practice's butt and make sure patient understands you are doing this FOR them but bottom line they are responsible for out-of-pocket.

PippiT:

--- Quote from: PMRNC on July 18, 2017, 05:49:52 PM ---Ok, since not ERISA, you pretty much have exhausted with the State Dept / AG. The Customer service rep's are covered by their disclaimer that " benefits quoted are not a guarantee...etc., etc."  The services are  "NON" Covered as you found out with even the state dept of insurance. At this point, what I would do is bill the patient as there is nothing else you CAN do. In meantime you can let the IRO play out, I would say to cover the practice's butt and make sure patient understands you are doing this FOR them but bottom line they are responsible for out-of-pocket.

--- End quote ---

Yes, that is the plan but I have to come up with studies and documentation for Amnioband and anything I can find to submit to help our case for medical necessity. I've googled a few things that can't hurt but without the providers cooperation I'm afraid I will not have the proper documentation. In the end I've done my part so it's all I can do. 

I'm not sure what the doctor is planning to do  regarding billing the patient. I relayed the message from the AG that he needs to be thinking about that possibility. I guess he's waiting for the IRO to play out before deciding next steps.

Thank you for your response, it confirmed what I already thought! 

PMRNC:

--- Quote ---I'm not sure what the doctor is planning to do  regarding billing the patient. I relayed the message from the AG that he needs to be thinking about that possibility. I guess he's waiting for the IRO to play out before deciding next steps.
--- End quote ---

Depending on whether the services were rendered or not it might be a good idea to at least discuss the "Plan B" options. If this were my client or even employer I would definitely discuss the plan B immediately. I would also take into consideration what the patient was told prior to services if they were rendered. This isn't something I would only "wait and see" about if the costs are high. If services were already rendered with the patient believing they were covered, certainly there can be more discussion with the patient on payment.

PippiT:
I wanted to give an update, the IRO was successful and they overturned all the claims. THANK YOU ALL for your responses, it helped me tremendously as this was my first claim to take all the way. I have a question, hoping someone can help me.

The provider disputes the Out of Network allowed amounts. I went through the proper channels and disputed the payments as they were repriced by Viant. Viant is saying they are not willing to negotiate. My question is can I send these claims to a CollectRX type company? Ssince these claims were paid by overturning I don't know if that would make them ineligible or not?

Michele:
First of all, congratulations on getting them overturned!  Good work!

So basically they did overturn and pay but the provider does not want to accept the amounts, correct?  If the provider is out of network they can bill the patient for the amount above what the insurance carrier allowed.  I'm not familiar with CollectRX in particular but it appears they are a revenue cycle management company.  Since you already did the work of getting the claims overturned it seems like you might not need a full service like them.  Have you tried billing the patient yet?  I would try billing first on my own.  If the patient indicates they aren't going to pay, or doesn't respond, then I would do something more like collections.  We use a soft collection agency that has great results.

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