The Process of Appealing/Filing a Grievance for a Commercial Insurance Claim Steve Verno 1

Disclaimer I am not a lawyer! I don’t provide legal advice. This presentation is for training purposes only! Samples contain NO actual patient information. All names are fictitious! 2

NO GUARANTEES! 3

We Will NOT Discuss! ERISA! HEALTH INSURANCE CONTRACTING 4

What we WILL Discuss! Timely Filing Denials No Authorization/Precertification Payment Less than Billed Charges Payment as a Non-participating Provider Denied as a Non-participating Provider Payment Sent to a Different Address Claim is NOT paid or denied Claim for Alleged Overpayment (Refund) 5

Another Insurance is Primary (Refund) Patient Never Revealed Medicaid Coverage Third Party Liability Information Not Received from Patient Benefits Expired or Terminated Seen Prior to Effective Date of Coverage Bundled Service Downcoding 6 What we WILL Discuss!

Information Requested from Provider not Received Not a covered Service 7 What we WILL Discuss!

Timely Filing Denial 8

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Proof 10

STATUTES FS AND : (3) All claims for payment or overpayment, whether electronic or nonelectronic: (a) Are considered received on the date the claim is received by the insurer at its designated claims-receipt location or the date the claim for overpayment is received by the provider at its designated location. (b) Must be mailed or electronically transferred to the primary insurer within 6 months after the following have occurred: 1. Discharge for inpatient services or the date of service for outpatient services; and 2. The provider has been furnished with the correct name and address of the patient’s health insurer. 11

THE EOB 12

The Patient’s Benefit Manual 13

Certified Mail/Return Receipt 14

Website 15

Provider Contract 16

No Authorization or PreCertification 17

18 No Authorization or PreCertification

Proof 19

State Law Requirements for providing emergency services and care.— (1) In providing for emergency services and care as a covered service, a health maintenance organization may not: (a) Require prior authorization for the receipt of prehospital transport or treatment or for emergency services and care. 20

State Law : A health maintenance organization must pay any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized by a provider empowered by contract with the health maintenance organization to authorize or direct the patient’s utilization of health care services and which was also authorized in accordance with the health maintenance organization’s current and communicated procedures, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization. 21

The Benefit Manual Your Benefits Although a specific service may be listed as a covered benefit, it may not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition. Refer to the “Glossary” section for the definition of “medically necessary.” Certain services must be precertified by XXXXX (name removed). Your participating provider is responsible for obtaining this approval. 22

Website 23

Provider Contract 24

Payment Less than Billed Charges/ Payment as Non-Participating Provider 25

Payment Less than Billed Charges/ Payment as Non-Participating Provider 26

PROOF 27

State Law used by HMO If a health maintenance organization is liable for services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider. 28

The Benefit Manual 29

The Benefit Manual 30

Denials as a Participating provider 31

32 Denials as a Participating provider

PROOF 33

State Law Each health maintenance contract, certificate, or member handbook shall state that emergency services and care shall be provided to subscribers in emergency situations not permitting treatment through the health maintenance organization’s providers, without prior notification to and approval of the organization. Not less than 75 percent of the reasonable charges for covered services and supplies shall be paid by the organization, up to the subscriber contract benefit limits. 34

The Benefit Manual 35

Payment Less than Contracted Amount 36

37 Payment Less than Contracted Amount

PROOF 38

The Contract 39

Payment Sent to a Different Provider 40

41 Payment Sent to a Different Provider

PROOF 42

Check to Correct Address/Claim form 43

Claim is Never Paid or Denied 44

Run Insurance Aging Reports Weekly 45

Verify! Verify! Verify! 46

Resubmit PaperClaims to CEO by Certified Mail 47

How do you Find the CEO? 48

Securities Exchange Commission 49

Securities Exchange Commission 50

Securities Exchange Commission 51

Securities Exchange Commission 52

Securities Exchange Commission 53

Securities Exchange Commission 54

Your State Division of Corporations 55

Your State Division of Corporations 56

Your State Division of Corporations 57

Your State Division of Corporations 58

Your State Division of Corporations 59

Always Send Certified Mail/Return Receipt 60

Keep Track with Tickler File 61

Don’t Let Your Claims Die! 62

Lets take a short break! 63

WELCOME BACK! 64

Check Uninsured Accounts for Insurance 65

Refund Demand 66

Refund Demand 67

PROOF 68

State Law 69 FS and All claims for overpayment must be submitted to a provider within 30 months after the payment of the claim. A provider must pay, deny, or contest the claim for overpayment within 40 days after the receipt of the claim. The Organization may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health maintenance organization’s overpayment claim as required by this paragraph.

Another Insurance Was Primary 70

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PROOF 72

Your Laws! FS & All claims for overpayment must be submitted to a provider within 30 months after the health insurer’s payment of the claim. A provider must pay, deny, or contest the health insurer’s claim for overpayment within 40 days after the receipt of the claim. 73

Insurance Affidavit & Insurance ID Card 74

Website Verification 75

Burden of Proof is on Them! 76

Patient Never Presented Medicaid Coverage 77

78

Proof 79

80

81

Third Party Liability 82

83

Letters of Protection Subpoena Subrogation 84 Third Party Liability

Information Requested from Patient & Not Received. 85

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PROOF 87

State Law Florida Statutes & Notification of the health insurer’s determination of a contested claim must be accompanied by an itemized list of additional information or documents the insurer can reasonably determine are necessary to process the claim. A claim must be paid or denied within 90 days after receipt of the claim. Failure to pay or deny a claim within 120 days after receipt of the claim creates an uncontestable obligation to pay the claim. 88

State Law Florida Statutes If a health maintenance organization is liable for services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider 89

Patients Benefits Were Expired or Terminated 90

91

Proof 92

Website Verification 93

State Law FS (1) - If a health maintenance organization is liable for services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider. FS (2) - For purposes of this section, a health maintenance organization is liable for services rendered to an eligible subscriber by a provider if the provider follows the health maintenance organization’s authorization procedures and receives authorization for a covered service for an eligible subscriber, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization. 94

Bundling (Service is included in the primary service or the service is included in a service previously paid) 95

96

PROOF 97

NATIONAL CORRECT CODING INITIATIVE (NCCI) COL 1 COL 2 MOD

CPT MANUAL Page 4 The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code 99

Insurance Contract & Benefit Manual 100

Downcoding 101

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PROOF 103

The EOB, Original Claim & Medical Record 104

Requested Information Never Received 105

PROOF 106

State Law FS & c) 1. Notification of the health insurer’s determination of a contested claim must be accompanied by an itemized list of additional information or documents the insurer can reasonably determine are necessary to process the claim. 2. A provider must submit the additional information or documentation, as specified on the itemized list, within 35 days after receipt of the notification. Additional information is considered submitted on the date it is electronically transferred or mailed. The health insurer may not request duplicate documents. 107

CERTIFIED MAIL/RETURN RECEIPT 108

NOT A COVERED SERVICE 109

110 NOT A COVERED SERVICE

PROOF 111

State Law Florida Statute : The Legislature finds and declares it to be of vital importance that emergency services and care be provided by hospitals and physicians to every person in need of such care Florida Statute : Each health maintenance contract, certificate, or member handbook shall state that emergency services and care shall be provided to subscribers in emergency situations 112

The Benefit Manual 113

The Benefit Manual 114

Filing an appeal or grievance Stick to the facts! Reference their error and your Proof! Never threaten! Do NOT Wait, respond immediately. Send everything Certified Mail/Return Receipt Allow them time to respond. If no response, file a grievance with the appropriate regulatory agency! 115

File Grievance with Regulatory Agency 116

Which One are YOU afraid of? 117

Never Give Up! Never Surrender Attitude! 118

Questions??? 119

Thank You 120