Issues with insurance companies

June 6, 2013

Question:

Jennifer,

I received a notification that Aetna is no longer reimbursing for our multplan patients.  It just seems like no matter the insurance company, we keep having more issues.  When should I get you involved versus handle in house?

Thanks,
Dr. G

Answer:

Dr. G, that is a very difficult question to answer but I will do my best. Many attorneys would answer that it is a good idea to have legal involved regardless of the stage or depth of the dispute.  This may be true, but certainly not economical.  My take is when it comes to insurance issues is that any issues that may be resolved at the practice level should be resolved at the practice level. Many such issues include claims disputes or appeals to claims decisions, or questions on coverage. The issue raised above - a coverage issue - may be resolved by contacting your provider relations delegate for the insurer.  Also, if a matter can be handled with the claims department, for example accessing the status of a claims appeal, you likely do not require the assistance of your counsel.  Although, do not hesitate to call your healthcare attorney if you are concerned about a strategy or situation.  Issues that should not be tackled by the practice, period, without the assistance of counsel include when a special investigations unit is involved, or when the word fraud or the word abuse is used or may be used - which includes where the practice may be or is being audited for quality assurance, medical necessity or potential overpayment. 

Similar to the NYC Subway mantra - if you see something, say something - if you see something going on with your payments or by your payors, say something.  Say something to the claims department, your provider rep, and if you still require assistance, your attorney.  If you see something really bad, such as an audit, say something to your attorney immediately - do not wait or it may be too late.