Frequently Asked Questions

askquestionsInsurance for Clients: Medical Billing, Claims, Approvals, More

From APHA’s Former Insurance for Clients Advisor

Note – this advice is intended to be a guideline only.
Some aspects of insurance claims and approvals will vary by state or insurer.

 

1. How should I decide whether to represent a prospective client in a claims or authorization dispute with her/his health plan?

You usually can obtain a basic understanding of the nature of the case by reviewing the Explanation of Benefits (EOB) and/or denial letter that the health plan sent to your prospective client.

Appeal rights of the prospective client should weigh heavily in deciding whether you can provide assistance. Remaining appeal rights can be ascertained from one or more of the following: (1) the denial letter; (2) the plan document which articulates appeal rights – this document often is titled Evidence of Coverage or Summary Plan Description; and (3) discussions with health plan and/or employer representatives. Most prospective clients who obtained coverage through an employer with an insured group plan or from the health insurance marketplace have a final right of appeal with their state department of insurance. 

2. How important are HIPAA authorizations in representing a client in a denied claim or health plan authorization?

Being able to speak with health plan, provider and/or employer representatives is valuable, and often essential, in effective client representation.

Typically, health plans will not speak to you at all without a HIPAA authorization from your client. Virtually all health plans insist on using their particular authorization form, which usually can be downloaded from their websites. Most other relevant parties should accept the HIPAA authorization that you use in your health advocacy practice. If you do not have one, you can find samples here.

3. Who is responsible for providing a pre-authorization request for a diagnostic test of treatment?

While a health plan member naturally would look to her/his ordering physician to explain medical necessity, most health plans will try to hold the member financially responsible if their pre-authorization process was bypassed. In most pre-authorization situations, the member should request and receive confirmation from the physician office of the time the pre-authorization request was submitted. Then the member should follow up with her/his health plan to ensure receipt.

4. The pre-authorization treatment request from my client’s physician was denied for lack of medical necessity. Her physician believes strongly that the underlying health plan medical policy is unfair and that treatment should be approved. What should we do?

Generally, the path of lesser resistance is requesting an exception to health plan policy instead of challenging the policy itself. Our goal should be producing the best possible outcome for our client, not to reform health plan policy.

5. When should I file an appeal on behalf of my client with her/his health plan?

While specific case situations may differ, a basic general guideline is to treat each available appeal right like it is gold – once it is used, it is gone forever. Most health plans offer informal discussion for resolution of member issues. It usually is prudent to exhaust all informal discussion avenues before entering the appeal process.

6. How should I contest a medical necessity denial from my client’s health plan?

A good place to begin is to obtain clarification from a health plan representative regarding the reason for the denial. Contrary to what many of us believe, health plans rarely act arbitrarily – their determinations generally are based upon facts and circumstances presented and their medical policies. Sometimes, the problem may be simple and easily rectifiable if, for example, the client’s physician used the wrong procedure codes in connection with a pre-authorization request.

More digging may be necessary in other situations – reviewing the content of the physician’s medical necessity request and the health plan’s applicable medical policy may be required. Many health plans make their medical policies readily available online.

7. Do unique facts and circumstances matter?

Facts and circumstances are different for each case and sometimes can carry great weight in resolving health plan disputes.  

8. After my client received an EOB from his health plan indicating that a claim for physician services was denied because it was not submitted within their 12 month requirement, he received a $1,000 bill from the physician who provided services to him 18 months ago. Should my client pay this bill?

First, the client’s health plan should be contacted to determine whether the physician was in your client’s provider network at the time services were rendered. If (s)he was a network provider, your client should only be financially responsible for the deductible and coinsurance, if any. Resolving the situation could be as simple as contacting the physician office to determine whether the bill was sent in error. If this effort is not successful, your client’s health plan should be asked to intervene with this physician – (s)he may be violating the terms of her/his health plan provider agreement.

The situation becomes much thornier if the physician was an out-of-network provider. Absent state law protecting health consumers from late billing of this nature, out-of-network physicians usually are free to do whatever they choose to do. The best you may be able to accomplish for your client is to negotiate a settlement with this physician for the amount your client would have been responsible for if the claim had been submitted on time and the health plan had paid its share. 

9. What should if I encounter an authorization or rejected claims situation that I do not feel capable of handling?

Begin by congratulating yourself for placing the well-being of your client ahead of your business self-interest. Most health plans can be formidable adversaries in member disputes – the health insurer with which I have had the most dealings has 15 full time medical directors and 21 full time attorneys on its staff. Even seasoned professionals who regularly represent clients in health plan disputes often look to outside peers to match the prospective client with the best possible representation.

If you think there may be a better professional fit for your client and know of an APHA member who may be particularly capable, feel free to contact that person. If not, start a new thread on our APHA Connect! Discussion Forum describing the case and requesting assistance. You almost certainly will receive replies.


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