Verification of Coverage Exceptions

This article is republished by the express written permission of ChiroCode Institute

PROBLEM

Knowing how to cope with invalid coverage information from insurance companies.

SUBJECTIVE (HISTORY)

In the quest to better serve their patients and clients, many offices verify coverage before rendering a service. One of the problems and frustrations is the validity of the information from the payer.

OBJECTIVE FINDINGS

Here is a typical example from a client:

“On March 26, we were told that the patient had coverage effective in December and that it was still active. We submitted our claim and it was paid. Now, all of sudden, they are saying the policy was canceled in February before our phone call, and they are asking for their money back. We had no knowledge of this cancellation and trusted them. We just followed normal routine procedures. I have appealed and my appeal was denied. What is my next step?”

ASSESSMENT

It appears that this office had a “Good Faith” issue. We suggested retaining legal counsel who is experienced in such matters. The suggestions below are by Mike Miscoe. Some key pieces of information that the provider will need to disclose to legal counsel are likely to include:
Who is the carrier and is the provider participating? Gather copies of contracts.
What provisions exist regarding return of various types of overpayments?
Who received the payment, the provider or the patient?
Has any off-set for the “overpayment” been applied to other claims?

Generally, an insurer will float an insured for at least 30 days for non-payment, and if they miss the second payment, they cancel to the last effective date of payment. This particular situation seems a bit extended, but the provider contract needs to be reviewed. If the provider signed a contract which allows the carrier to do what they are doing, the provider is stuck (absent any state law to the contrary).

If this is an ERISA type claim (health plan sponsored by an employer in the private sector, you should first exhaust the ERISA appeals process, and then go to Federal Court with good legal counsel.

If not ERISA with a small balance (by your state’s definition), and they give you a “demand notice,” you might want to consider filing with your Small Claims court. Also. depending upon your written agreement(s) with your patient, it could be their responsibility.

Such are our initial thoughts. Remember, there is no substitute for good legal counsel experienced in such matters.