Doctors fight unfair pay-pay tactics; Does it work?

Doctors across the country are mired in battles with insurers who seem to be finding new ways to try to avoid paying them. Many fight back in different ways; some are more successful than others, and each has its advantages and disadvantages. Would any of these methods work for you?

  • Barbara McAneny, MD, says she hires “high-heeled pit bulls” to work with pre-clears and get paid for her practice. “Successful practices are very effective in tracking and combating denials. We fought all the way down to Medicare administrative law judges, which in one case took almost 3 years, but we finally got our money,” AMA alumnus McAneny says. President and CEO of Hematologic Oncology Specialists in Albuquerque, New Mexico.

  • Attorney Steve Cohen, JD, of Pollock Cohen, LLP, in New York City, says he represents a doctor who performed 20 procedures more than 10 months ago that he says approved by Emblem Health but never paid for. Since this violates New York’s 30-day prompt payment law, the doctor can now charge their entire $ 5,000 procedure fee plus 12% interest instead of Emblem’s negotiated rate of 1. $ 800 for each procedure, explains Cohen.

  • A lawyer for Duane Morris, LLP, says his firm helps doctors in 26 states collect payments from insurers. “Payers seem to unilaterally decide what the appropriate payment is and then come up with a basis for reducing or denying the benefit or payment for that service,” says Greg Brodek, JD, chair of the healthcare law practice group and head of the practice of managed care litigation. “This practice is incredibly widespread. We have $ 100-300 million in payor claims at any given time that we are suing on behalf of physicians in private practice.”

Brodek says most of the lawsuits he has taken in recent years on behalf of doctors have been against United Healthcare, followed by Anthem and Aetna. Legal actions include formal notice, mediation, arbitration and legal action, as a last resort.

These battles are paying off for doctors. “We have settled the vast majority of lawsuits over the past 10 to 15 years, recovering over hundreds of millions of dollars for our clients,” said Brodek.

McAneny says hiring additional staff to pursue insurance payments has paid off.

Pre-authorization No Guarantee of Payment

Many doctors have probably ignored the brief warning on pre-authorization forms that approval is not guaranteed payment.

The original intention of the disclaimer was to allow payers to say that beneficiaries were not eligible for benefits if they opted out of the scheme or obtained different insurance between the time of pre-certification and the procedure, explains Brodek.

“But now that has been transformed into a much broader discretionary sentence that allows payers to say that you are pre-authorized, but now that we have looked at the claim we have decided that it is experimental, not medically necessary or not covered. service, or many other reasons they give for refusing coverage that they haven’t historically done. “

He does not believe that many of the actions taken by payers under prior authorization are legally permitted. “I spend a lot of my time fending off providers who have secured an assignment of patient benefits who are now being told, ‘Oh, the injections of Part B drugs as part of your Medicare plan. Advantage is not covered and we will not pay you, the supplier. ‘ We go back to the payer and say these were pre-authorized by you and you refused them; you are not allowed to do this under the contract, benefit plan, or law of the ‘State. “

Another troubling trend is prepayment exams, which can drastically reduce the income of doctors, says Brodek.

A common practice is to review the level of rating and management codes that physicians charge, and then “decode” them to a lower and cheaper level of service.

Brodek says he is representing at least 1,500 doctors in a consolidated lawsuit to recover a total of $ 18-19 million in 18-month loss reductions from an insurer he refused to disclose. He says consolidating multiple plaintiffs into one action is much more effective than filing class actions.

Another way to reduce physician payment is when insurers extend the payment process by requiring patient medical records or other documents to be manually submitted along with claims. Once the insurer receives the documents, it can determine whether the claim is appropriate, should be reduced or reclassified, or if more documentation is needed, Brodek says.

“This process can take 6 to 12 months, after which the vendor gives up and just says, ‘Pay me what you think is appropriate,’” says Brodek.

Fighting against the denial of prior authorization is expensive

McAneny’s practice has a staff of 230, including 20 physicians and other providers. The firm employs 10 full-time people who only work with prior authorization, in addition to the 20-person billing office that regularly deals with around 40 insurers.

Dr Barbara McAneny

“Although it’s expensive, it’s worth it. If we don’t have the staff to do it, then the doctors have to do it, which means they don’t see any patients. I don’t want my most expensive employee is doing this job, which includes faxing hundreds of records to the insurance company. The alternative is not to do it, and the patients are not being treated! ”says McAneny.

Dr Daniel Edney

Daniel Edney, MD, physician in internal medicine and addiction medicine with Medical Associates of Vicksburg, Mississippi, says, “We pay a lot of overhead to process pre-authorizations, insurance denials, and drug approvals.

His firm of 11 suppliers, including four doctors, regularly deals with nine insurers. Getting pre-cleared takes so long that he had to hire two more full-time employees just to focus on that. This is in addition to the time spent by two administrators.

“We have to be aggressive and strategic. That’s why we have employees trained to identify these issues and know what buzzwords to use and what boxes to tick to get him to pass a first exam,” says Edney.

McAneny conducts peer reviews with doctors hired by insurers when benefits are denied. She completed 21 of those 12-day reviews in 2020 and had a 75% approval rate, according to data from August 2020 that she submitted to WADA.

But, the planning of these exams is done at the convenience of the insurers and not the doctors. “If I miss an appointment because a patient’s visit takes longer than expected, the appeal process will start again, which adds more time to get pre-clearance. What kind of priority is it when I interrupt the conversation with a patient to go talk to insurance? business?”

A 2020 AMA survey of 1,000 practicing physicians found that the average practice engages in 40 pre-authorizations per week and that physician offices spend the equivalent of two working days per week completing them. In addition, 85% of participants reported a high burden associated with prior authorizations.

Insurers also change their criteria, processes and rules every month, according to Molly Smith, group vice president for public policy at the American Hospital Association. This creates a bureaucratic nightmare for practices dealing with multiple insurers.

They just can’t keep up with all the changes and then make mistakes as they submit a rule-based pre-clearance request last month, Smith says.

“It often happens that they push back a lab because they changed the ICD-10 code that they had approved for months.

Brodek says the payers’ contracts contain provisions stating that providers will agree to their policies and procedures. “Insurers have gotten very smart; instead of changing their contract, they unilaterally change a policy or procedure that suppliers must then follow. “

Suppliers are often notified of a policy change when the billing office informs them 6 to 12 months later that their payments have dropped exponentially and that’s why, explains Brodek.

Driving doctors into bankruptcy?

Not all private practices can afford to hire additional staff, Brodek says. “It has become very difficult for solo practitioners to stay in business unless they have a great specialty where they can dictate a fairer relationship with the payer. Otherwise, if you are a primary care physician or an anesthesiologist, pathologist, or radiologist, you have no power.

But even private firms that have additional staff to deal with insurers are feeling the financial impact. “In a doctor-owned practice, the bottom line is that the owners get paid last, which means the doctors make less money. This is a problem because it is difficult to compete with hospitals which can afford to pay providers much more than I as a doctor. independent fee-for-service practice, ”says McAneny.

Fewer physicians (49%) are in private practice than in the past, WebMD reported in May. The results of the AMA 2020 survey also showed that more doctors are working in large doctor’s offices and in hospitals.

The insurance industry reacts

David Allen, spokesperson for America’s Health Insurance Plans trade association, commented on pre-authorization practices in a statement.

“Prior authorization helps ensure that patients receive safe, effective and necessary care. “

Less than 15% of the services, procedures and treatments covered require prior authorizations. Insurers only use prior authorization in certain circumstances, including for prescription drugs and services that require special care, such as when the risk of addiction is high, such as opioids for chronic pain, when Drug interactions can be dangerous and when unnecessary treatment can be harmful such as “inappropriate diagnostic imaging such as CT scans for back pain”.

In these limited circumstances, prior authorization:

  • Protects patients and prevents overuse, misuse or unnecessary (or potentially dangerous) care

  • Ensures care is consistent with evidence-based practice

  • Can help reduce a patient’s personal expenses

“We know that prior authorization can be improved. We can balance efficacy and evidence with safety and necessity. We are committed to reducing unnecessary burden, increasing patient satisfaction, and improving quality and outcomes. “

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