Chiropractic Pre Authorization Blues

2010-06-10T19:19:51Z

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.

TMB staff 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.

So 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.

Being one of the best billing services in the country, it is our job
to get the absolute highest pay for the doctor, so we always take
that extra step and get 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.

Tru Medical Billing 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 we 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, we 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.

In my next blog I will talk about the logistics and details of the appeal.

From site:

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.

TMB staff 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.

So 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.

Being one of the best billing services in the country, it is our job
to get the absolute highest pay for the doctor, so we always take
that extra step and get 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.

Tru Medical Billing 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 we 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, we 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
authorization 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.

In my next blog I will talk about the logistics and details of the appeal.

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2010-06-02T02:23:09Z

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Chiropractic Pre Authorization Blues

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