Provided by: Jennifer Kirschenbaum, Esq.
February 26, 2019
Question:
Hi Jennifer,
I practice evidence based medicine and I follow very clear studies when it comes to how I care for my patients. Recently there has been a very aggressive push by a payor to deny what seems like any surgery with loose understanding of our data. I have to spend time on the phone and it always gets approved but it’s time out of my schedule, a hassle for patients, and a drain on my staff. Very clear misunderstandings regarding diagnosis, treatment options, etc. it’s almost as if they don’t care and just want to slow down the chains. My question is what is my recourse?
Thanks, Dr. K
Answer:
First, you hit the nail on the head – stall tactic to delay and deny payments.
Second, there are a few tactics we can employ in the initial instance before getting very aggressive, including, contacting your local provider representative for the payor and requesting an opportunity for an educational call, or requesting a meeting with the claims manager. Carriers will engage in these meetings (oftentimes) and will update your credentials and profile to take away such delays. If you do not get anywhere with the request, you may want to engage counsel to start this non litigious potential resolution for you. If they do not take you seriously, they may take your lawyer seriously. If this does not work, we could get more aggressive and start filing complaints to the Department of Finance for every claim that is “messed with”. Thereafter, we could get more aggressive and look to use the NYS Prompt Payment Law as fire against them, and also potentially your participating provider contract.
Hope this helps!
Second, there are a few tactics we can employ in the initial instance before getting very aggressive, including, contacting your local provider representative for the payor and requesting an opportunity for an educational call, or requesting a meeting with the claims manager. Carriers will engage in these meetings (oftentimes) and will update your credentials and profile to take away such delays. If you do not get anywhere with the request, you may want to engage counsel to start this non litigious potential resolution for you. If they do not take you seriously, they may take your lawyer seriously. If this does not work, we could get more aggressive and start filing complaints to the Department of Finance for every claim that is “messed with”. Thereafter, we could get more aggressive and look to use the NYS Prompt Payment Law as fire against them, and also potentially your participating provider contract.
Hope this helps!
