Can They Really Do That?

Top 5 Questions Posed to the Health Systems Committee

• #1 – Can insurance plans have different fee schedules for different types of providers?

• #2 – Can insurance plans sell my participating provider contract without my notification?

• #3 – Can insurance plans outsource or exclude me from performing certain procedures allowed by my scope of practice?

Top 5 Questions Posed to the Health Systems Committee

• #4 – Can insurance plans ask for money back on previous paid claims, and if you don’t comply, can they take money out of a future claim payment?

• #5 – How can I fight back?

Strategy Basics• Research the issue – understand the scope of the

problem and avoid jumping to conclusions

• Determine your legal rights with regard to the issue

• Working with the plan – develop a strategy that appeals to what plans care about

• Communicate with the correct people at the plan

• If you escalate to policymakers, cast the issue in terms of public policy

#1 – Different Fee Schedules? The Basics: What Law Applies and Who

Regulates the Plan?

Series10

10

20

30

40

50

60

27.8

9.1

15.3

59.3

Government

Direct Purchase

Not Covered

Employer Based

#1 – Can Insurance Plans Have Different Fee Schedules for Different Types of

Providers? • Applicable Laws

– Medicaid – State/Federal– Medicare – Federal– Military – Federal– Direct Purchase – State– Uninsured – State

#1 – Different Fee Schedules?

• Employer Plans – ERISA– Insured are

regulated by state and federal law – if it is in the insurance code, it probably applies

– Self-insured are regulated by federal law

1st Qtr0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

45

55

Self In-sured

Insured

#1 – Different Fee Schedules?

• What to Know and Do About Employer Sponsored Plans– In firms with 5,000 or more employees, 89% of

workers were covered by self-insured arrangements in 2006

– Does the insurance card have the employer logo?

– Call the plan administrator – Always pre-certify your patients so you know the

“paying" field

#1 – Different Fee Schedules?

• What If I Don’t Like the Fee Schedule?– Renegotiate your contract– See chapter 2 in the Private Insurance Resource

Guide (PIRG)– Evaluate your current office profit/loss ratio for the

particular insurance plan• Survive without it • Need it to survive

#2 – “Sell” My Contract ?

• Yes, look at the original contract for language such as “deemed” provider or the definition of payer

• Very common if you signed up with multiple PPO contracts in the late 80s or early 90s that have merged over the years (Ex. Multiplan)

• A review of your state laws may be help

#3 - Exclude Me from Certain Procedures?

• Review your contract thoroughly– Example: Orthonet

• Definition of experimental or investigational– Insurance plans typically exclude coverage for

services that are “experimental, investigational and/or unproven.”

– Confusion sometimes arises because plans may be imprecise in how they categorize denials based on such exclusions.

• Within the range of covered services, private plans typically cover only items and services that are medically necessary and appropriate.

#4 - Ask for Money Back?

• Review the insurance company’s specific claim that states you owe them money – if not, ask for additional information.

• Review your contract to see what your rights are for these type of claims– Did they reserve the right to do recoupments?– Do they have the right to offset the amount

against future payments?– Is there an appeal mechanism specified, and if

so, does it include timelines?

#4 - Ask for Money Back?

• Recoupment Reasons– Overpayment– Retroactive denial– Individual was not eligible– Service was not covered– Miscoordination of benefits – it was subsequently

determined that another payer was responsible

#4 - Ask for Money Back?

• More Recoupment Reasons– If the recoupment is due to the beneficiary not

being “eligible” for coverage, you can bill the beneficiary.

– If the recoupment is the result of a payer coordination issue, is it timely enough that you can receive the funds from the other payer?

– Does the recoupment affect the amount you should have received as patient cost sharing?

#4 - Ask for Money Back?

• If there is an available appeal process, file an appeal– Write a detailed appeal letter about the claim in

question. – Cite any contractual provisions and laws that you

believe are violated by the recoupment.– If the recoupment changes the amount you

should have collected in cost sharing, note your intent to collect the additional funds.

#4 - Ask for Money Back?

• Appeal Process – continued– Call the plan and ask to discuss the issue with

either the head of claims or provider relations.– Using a multi-pronged approach to increase the

chances that your concerns will reach someone who cares and someone in a position to address the situation.

– Keep records of your correspondence and the people you talk to.

#4 - Ask for Money Back?

• Applicable laws regulating recoupments– Determine what law is applicable (e.g., federal,

state, program-specific law).– Laws regarding retroactive denials and other

recoupments are frequently found in the section of the state code that sets forth prompt-payment laws, laws concerning unfair (or fair) insurance practices, or claims settlement rules.

#5 - How Can I Fight Back?

• Review chapters of PIRG regarding appeals process-different for ERISA vs. Non-ERISA plans

• Review and know your state laws - Chapter 9

• Review and utilize sample letters - Chapter 12

Visit http://www.apma.org/privateguide

#5 - How Can I Fight Back?

• Contact the agency in charge of enforcing the relevant law if no agreement is reached– Provide concise facts regarding the issue– Provide history of your efforts to resolve it– To the extent possible, cast the issue in terms of

public policy

#5 - How Can I Fight Back?

• Issues commonly addressed by the law– Prohibition on retroactive denials for

preauthorized services– Timelines for recoupments or retroactive denials– The information that a health plan must furnish if

it requests a recoupment– Whether an offset is allowed and/or whether an

appeal must be allowed– In general, if the applicable law offers more

protection than appears in the contract, the law will apply

#5 - How Can I Fight Back?

• Sponsor Legislation – In 2009, APMA’s State Advocacy Committee and Health

Systems Committee initiated the Model Law Project to protect podiatric physicians and surgeons from discriminatory and unreasonable practices by payers.

– Next Model Law Project: Retroactive Recoupment Model Law

– This model law is intended to address deficiencies in state law that allow payers to recoup payment in an unreasonable manner.

– A model retroactive recoupment law will be available later this.

Model Legislation

• Model Fee Parity Project– Section One: Understanding Fee

Discrimination Laws. – Section Two: Obtaining Enforcement of

Existing Law– Section Three: Introducing Fee Parity

Legislation– Section Four: Resources for State Advocates– Available at: www.apma.org/modellaws

Model Legislation

• Model Anti-Fee Discrimination and Fee Parity Act– Payment may be based on several factors

including market power, geographic location, or need to include a physician specialty

– Model Law prohibits fee discrimination when the difference in amount of payment is based solely on the fact that the physician is a DPM rather than an MD or DO.

Questions?