Avoiding Run-ins with Commercial Insurance Payers

Monday Monitor

June 2, 2014

Good morning, Chuck. Thank you.

When it comes to commercial carriers and audits, a couple of fundamental rules that we apply, and this goes for all audits but with different types of providers, it is an important advice: don’t touch the records. We can address any deficiencies, but by touching the records, you get into all kinds of other problems. So, don’t fix them up before the auditor comes.

Two, you do have to look at the contract, but you have to challenge the appeals process. The most important thing that I’ve learned over the years is: one, you have to lock the commercial carriers into a position because they can change their position, and, two, you have to try to get to an independent fact finder to get resolution. If you have a commercial carrier and they only give you an internal process, then you’re going to have greater difficulty winning. One thing that you should be aware of, and it’s part of the ACA, but every state is required to have a consumer component for commercial appeals. We use it in Michigan and other states. Health systems and providers can use it, particularly for big ticket items. But consumers have a right to go to an IRO under federal law and get a determination. So if you have an appeals process that is not meaningful for the provider, if you incorporate the patients into the process, then you can get something independent. I also look at, we challenged the process, we’ve had a lot of fun with commercial carriers in the past. They used to have no process, come in, disallow everything and take your money. We used to have to go into circuit court and get injunctions and we’ve had all kinds of fun with that. Such as, one time we filed a lien because they didn’t file a bond on appeal when we won an $80,000.00 case. It ended up that Blue Cross Blue Shield of Michigan could make absolutely no payments out of their accounts. They were all frozen until they settled our case. So that was kind of fun.

But, bottom line is you have to look at the process, don’t accept their process. I treat the managed care contracts with Medicaid a lot like commercial carriers. They’re commercial contractors. They do not always provide the appeals process that you are entitled to. We have had these commercial carriers that manage these contracts give no appeal rights. When, if you look at their contact with the state, they are required to give appeal rights. We’re seeing also a lot of narrow network terminations of physicians and I think one has to look beyond the contact, one has to look at their contact with the state, one has to look at the right of the Medicaid patient’s right to access, and all of these issues if you are going to challenge it.

I’d like to close with just emphasizing our presentation on Part B and non-hospital Part A providers and appeals from Medicare and Medicaid and commercials will present on Wednesday at 1:30, and although the RACs may be slowed down a bit on the inpatient/outpatient, there is significant activity in areas that interest health systems with the level of integration that you have for hospice, home health, skilled nursing, physicians, DME, independent clinical labs, imaging centers. We’ll talk about all of this and the key issues facing providers.

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