Appeal Denial, a Play in 4 Acts

The transcript below is a real email conversation I had with a patient who was trying to appeal a denied service. Reading this might help you avoid some of the delays we had with the appeal denial process and give you some direction on the steps you need to take if you want to file a claim appeal. The example refers to CPT Code 93880, which is a CIMT test performed at our office and often denied by out-of-state health insurance companies. You can potentially adapt the conversation to any CPT code, service, and price, as the process is very similar for appealing almost any denied service.

If you have any questions, please contact Ryan!

The Appeal Denial Begins (Act 1)

ME: We just received a denial for your CIMT test from February stating it was a “non-covered service” on your plan. That is the only information we received on our end – would you possibly be able to share the information on your statement with me so I can figure out if there is anything we can do for the appeal denial? Depending on why they determined it to be “non-covered,” we may have a few options available to get it covered. Thanks!

PATIENT: How much is it if it isn’t covered? I could dig into it a bit more, but if it’s hundreds of dollars, I’ll be extra motivated. 🙂 Are they usually covered by patients’ coverage?

ME: Yeah, it is usually covered. I was surprised to get the denial. It was $198.65, so it’ll probably be worth trying. I kind of enjoy trying to win these appeals, so I hope you’ll give it a shot! 🙂

PATIENT: I’d love to give it a shot! I’ll put that $200 to much better use. Is there any information I can send along in the meantime? I have had poor cholesterol and my family has a history of heart disease. The test revealed some unfortunate news about my “arterial age” and led to a cardiologist visit. Does that help my case? 🙂

ME: Your EOB from your insurance will probably have more details – I have attached the version I received on my end. Can you see what details yours shows? I’m not sending you an invoice since I think we can get it covered, but I can if that might help. A letter of medical necessity is one of the last options we have for an appeal, so that information should help if we get to that point. Hope it is easier than that, but we’ll see what your EOB says and go from there. Thanks!

Eight Weeks Later (Act 2)

PATIENT: Still no EOB in the mail. I wonder if I’ll ever get anything. Could we move forward in some other way?

ME: Do you possibly have electronic-only EOBs enabled? Can you login to an account with your insurance and look at your claims?

PATIENT: Good thoughts. I do have access to my online account and there is an EOB in there! I attached it. There’s not much more in there, unfortunately. What can I do to help this effort?

ME: You may need to call them to get a better reason why it was considered non-covered. Sometimes, they just accidentally call it non-covered and as soon as you try to ask them why, it magically gets fixed immediately. The EOB is good to have if we’re filing an appeal, though, so that can be your proof of a denied claim (one of the three things they’ll probably need to initiate an appeal). I know it’s a hassle, but it’s really helpful to have an actual reason why it is non-covered before trying to submit anything just so we don’t run into the same problem after an appeal.

Someone at your insurer’s customer service department should be able to answer this question: “Why was CPT Code 93880 considered a non-covered service under my plan?” The process for an appeal denial is pretty much the same no matter what, but we’d give them different content depending on why they claim its non-covered. I hope that helps!

PATIENT: Great, thanks Ryan! I’ll give them a call soon and ask that exact question. I’ll be in touch.

Two Weeks Later (Act 3)

ME: Just an update to let you know BCBS requested all records related to the CIMT service. I just sent them about 20 pages worth of notes your provider thought were relevant, so we’ll see how they respond in about 4 weeks. You should get a long letter in the mail if it is denied again, or a short letter if they approve it. Your letter usually arrives about 2 weeks before ours, so let me know which you get and I can start fixing the new outcome a little sooner.

PATIENT: That’s great! Thank you for staying on top of this, Ryan. I have so much else to do during the day, I’ve been kicking the “call BCBS” can down the road. It sounds like they’re still in the process of determining whether it should be covered. I appreciate it, as always.

Three Months Later (Act 4)

ME: Have you heard anything yet? I received a appeal denial saying it was duplicate (meaning they didn’t change their mind about it being non-covered) a few weeks ago, but nothing else. Did you happen to get a full explanation of the appeal’s denial? Thanks!

PATIENT: Huh… you know, I never received anything more in the mail, and I never checked back up on my dashboard. I’m doing that now…Okay, done looking it up. It does look like I have 2 outstanding claims and I owe ~$200, but that seems lower than I recall it being. Both are for “Vascular Study.” Let me know if there’s any more info I can get you. I should probably pay this dang claim if I haven’t already.

ME: That kind of confirms what I got – just hoping for better news from you. I’ll send you an invoice so you can use your flex card to pay the balance. Thanks for the reply!

Insurance Terminology 101: “Approvals” and “Authorizations”

Insurance Terminology 101: “Approvals” and “Authorizations”

One commonly misunderstood concept about insurance coverage is the term “approval.” It seems pretty simple, but many people think that having a service approved by their insurance plan means that they will not have to pay for the service. While that is possible depending on the situation, the most often result is that the patient is left surprised and confused when they ultimately receive a bill for an “approved” service. This post is part of a series to help patients clarify the terminology that your insurance company is using so they can better understand their coverage.

Approval / Authorizations

Approval by an insurance plan means that they will allow you to get something done and will at least consider paying for the test. This does not mean that your health insurance will pay for the test – it means they agree that the procedure will be subjected to the benefits listed on your insurance plan. Authorizations are essentially the same thing as approvals, but you’ll hear authorizations more often with prescription coverage details. Just like approvals, a prescription authorization only means your insurance benefits will be applied to the claim for your prescription and does not guarantee payment.

While you may still be paying for an approved service, your insurance company at least acknowledges that this test or medication is generally recommended for your particular medical situation and should be considered as part of your plan’s benefits. They are not saying they won’t pay yet, but they also aren’t saying they will pay, either. This is the first chance in the claims process for your insurance company to get out of paying for a service, so getting this approval is a good first step.

However, obtaining an approval does not mean you will not still owe up to 100% of the service you are approved to receive. Your benefits for an approved service could include deductibles, coinsurances, copayments, and additional out-of-pocket expenses that you will have to pay the service’s provider. If you have a high deductible that has not been met, for example, you will still incur a large out-of-pocket expense for approved services.

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Let me know what you think in the comments section below. If there are any other phrases or terms that you sometimes get confused, please send me a message and I’ll try to feature your question on a feature post. Thanks for reading!

How To View Online EOBs

This is a basic description of what you’ll need to do in order to access your Explanation of Benefits (EOB) statements online. Since the majority of our patients are insured through Blue Cross Blue Shield of North Carolina, we will use their website and process as an example. Most insurers have something similar available on their own websites, so if you have a different insurance plan, you can try to take some of the concepts and adapt them to your own insurer. You can contact the individual insurer to find out how to view online EOBs for that specific insurer.

The first step, is to sign up for an online member account. For BCBSNC, you can do that by clicking here and completing the registration process. To sign up for an account, you will need your Subscriber ID Number (available on your insurance card), Date of Birth, and Zip Code on file for the primary subscriber on your plan. If you already have an account, you can click here to login.

Once you are in your account, your screen should look something like this:

health-insurance-enable-online-bcbs-screen-shot

From there:

  1. Click on “Claims” on the top bar. You are now at a screen that can show you all of the medical and pharmacy claims that have been filed by your providers.
  2. You can expand the line items by clicking the + sign and then download the individual PDF files for the individual claims, if you’d like.
  3. Click on the link to download the PDF of the EOB, or just review the plan details shown in the online tool.

This is just a brief overview of the process for checking your online Explanation of Benefits statements for BCBSNC members. The Blue Connect online account has a lot of other great features (eg. deductible status, billing statements, prescription history, network access, etc.) for patients who want to manage their health insurance plan and usage,  so it is definitely worth signing up for any online tool your insurer offers. The screens will obviously be different, but the concept of “logging in to your online account and clicking the claims tab” should be pretty consistent.

In the rest of the blog posts in this series, I will explain the specifics involved in your EOB, including detailed information on the following topics:

  1. What is an Explanation of Benefits Letter?
  2. Basic EOB Terminology
  3. Determining Patient Responsibility
  4. Determining Plan Details
  5. Accessing Online EOBs
  6. Understanding Denials and Denial Codes
  7. How To File an Appeal

If you have any specific questions or topics you would like us to discuss, please mention them in the comments below and we will address them in future posts. If you are a patient at Family Care and have any questions about EOBs you received for claims from our office, please let us know by filling out our contact form. Thank you!

Determining Plan Details

Determining Plan Details

One of the most common problems that people experience with their health insurance is the frustration of having to pay out-of-pocket for a service or prescription that they thought would be covered by their insurance plan. “I thought that was covered” is a common phrase with patients and most of the negative perceptions of health insurers stem from the general distrust that this reaction causes. People are skeptical about insurers covering certain things because they have been burned in the past and see insurers as being greedy whenever they end up owing more than just their premiums for their healthcare expenses. While insurers do sometimes make mistakes and deny things that should be rightly covered (which you have the right to appeal), your insurance is usually processing your plan’s benefits exactly how they said they would when you signed up for the plan. They probably even have your signature on a sheet of paper saying you agreed to their terms. Sneaky, I know.

The problem usually begins because patients misunderstand their coverage and get surprised when they see the differences in benefits from what they thought they would have to what they actually have. The new Farmers Insurance commercials are really a perfect example. Knowing your coverage could influence your decision on where and when to get treatment and help you reduce your overall out-of-pocket expenses. It will also keep you from being surprised with unexpected bills or regretting services that you wouldn’t have done if you knew the cost. You may even change plans entirely because you realize your coverage is terrible, or if you are paying too much to have coverage for services you don’t need.

Because all plans are unique, it is impossible to make a single guide that covers everyone to determining your coverage. This post is designed to help you understand the thought processes and terminology behind determining your plan’s details so you can navigate through your own insurer’s information with a good idea of what you should be looking for.

Which health insurance plan do you have?

This is probably one of the first questions you’ll have to answer and is the starting point for all other questions you’ll be asked in every possible healthcare situation. When someone asks you what health insurance you have, what do you say?

bcbs_insurancecard
Example Insurance Card

There are two things your healthcare provider or pharmacist is always looking for when they ask this question.

  1. The name of your insurance provider. This is the most basic starting point and 100% necessary for your provider to determine your plan details. Examples include Blue Cross Blue Shield (BCBS), CIGNA, Aetna, United Healthcare, etc.
  2. The plan type and/or name of plan. This is the first subsection of the insurance provider and describes the plan option you chose when signing up with your insurer. Sometimes the plan has an actual name. Examples of BCBS plans include Blue Advantage, Blue Value, Blue Options, Blue Saver, State Employees Health Plan, etc. The plan could also only be described by letters, like PPO, HMO, POS, EPO, etc.

Depending on the situation, your provider might also need some additional information. Typically, you will be asked for the rest of this information if you are going to be receiving medical services or prescriptions, if you need a prior authorization for anything, or if you are being referred to another doctor.

  1. Your Subscriber Number. This is the first basic identifier on your insurance card. It may also be called your Member Number, Identification Number, or something else similar. This is the biggest and most important number on your card, so it is probably highlighted in some way. If you have dependents on your plan, the Subscriber Number includes the two digit suffixes assigned to each dependent. For example, Dad could be ABCD0000-01, Mom could be ABCD0000-02, and Daughter could be ABCD0000-03.
  2. Your Group Number. This is usually the second most featured number on your insurance card and allows your provider to see which pool of subscribers has a similar plan. This is usually unnecessary for most purposes, but is generally required if you need a prior authorization so it is good to have on file. The group number also helps providers figure out your plan details when you have private employer-based plans or some of the more obscure plans available that they might not see that often.
  3. The Payer ID # or the Billing Address. This is necessary for billing your insurance, but most providers already know the proper way to bill your insurance provider and don’t necessarily need it if you have a popular insurance plan. If your plan is based out-of-state or if you have a smaller, more obscure plan, you will probably be asked for this information. The Payer ID # is a 5 digit number on the back of your card and should be somewhere near the Billing Address.

That information will help your provider process your claims, send referrals, and obtain necessary prior authorizations. It will not allow your provider to tell you how much you will owe for a service or what types of benefits you have on your plan. Knowing your basic plan details only guides your provider so they can use the proper channels to correctly process your insurance benefits – it will not help them predict what those benefits will be, or even if there are benefits allowed for a service, at all.

Because plan details can vary on an individual basis, it is impossible for your provider to predict your benefits with complete certainty. We process the claims at the time of service with every piece of verifiable information we have available, but there are always surprises.

For example, you may pay a $20 copay for your visit. Then, after your plan processes the claim and says you are not covered for that service, you find out that you are required to pay 100%, instead. This is why it is important for you to know your own coverage – you are the person that is impacted by how your claims are processed and are ultimately responsible for any surprises that happen with your plan, so it is best to avoid them!

What are my benefits for this service?

The primary thing everyone wants to know – how much do I have to pay for this? There are several methods you can use to figure out your plan’s details for a particular service and the types of benefits you can expect to receive.

  1. Look at your insurance card. This is a “snapshot” of your coverage and usually shows the most pertinent details of your plan. The problem with relying on this is the lack of detail and explanation for your coverage for specific services, or the types of exclusions or exceptions that may be active on the plan. With most plans, this shows what you’ll need for the majority of the services you’ll receive.
  2. Reference your enrollment paperwork and benefits package. Whenever you sign up for a new insurance plan, your insurance provider is obligated to send you a detailed package that includes your plan’s coverage benefits. This is usually sent within a couple weeks of your enrollment and may be updated each year with a new packet of information. Usually, there is a table of information included with three columns – the service type, the plan’s in-network benefits for that service, and the plan’s out-of-network benefits for that service. Whenever you visit a provider or facility, reference their section on this table to help predict what your benefits will be for that visit.
  3. Contact your insurance provider. On the back of your insurance card, there should be a customer service number that you can use to ask any questions you may have about your plan. They will always give you a standard “this call does not guarantee payment of services and benefits will be subject to the plan’s details at the time of service” spiel to make sure they aren’t promising coverage they can’t provide, but they should be able to tell you what your copayments or deductibles are and how they apply to certain types of providers and services. Most plans have online portals with customer service emails or live chats, as well, but the process is the same. You’ll want to contact your provider for the CPT Code they will use for the service and ask your provider specifically about your benefits for that code.
  4. Look at how previous visits processed under the same plan. Past coverage is a good predictor of future coverage, but only if the plan’s details have not been changed. If you had a $25 copayment for a sinus infection six months ago, and your plan has not changed since then, you will probably owe a $25 copayment for a sinus infection today. This could be a little problematic because it refers to your benefits at a previous date, rather than your benefits today, so make sure your plan details have not been modified since the service you are using as a reference.
  5. Just hope something is covered and deal with it later. This is probably the worst option, but it is usually the one most people end up choosing because they are either intimidated or frustrated or confused with the process for actually understanding their benefits. Because this experience just ends up perpetuating the “patient-versus-insurance” mindset, when the two should be working together towards the mutually beneficial goal of reducing the cost of healthcare, I hope this post helps people avoid this option!

This was a basic summary of ways you can determine the details on your insurance plan.  This is the fourth post in a series on understanding the insurance claim process. In the rest of the blog posts in this series, I will explain the specifics involved in your EOB, including detailed information on the following topics:

  1. What is an Explanation of Benefits Letter?
  2. Basic EOB Terminology
  3. Determining Patient Responsibility
  4. Determining Plan Details
  5. Accessing Online EOBs
  6. Understanding Denials and Denial Codes
  7. How To File an Appeal

If you have any specific questions or topics you would like us to discuss, please mention them in the comments below and we will address them in future posts. If you are a patient at Family Care and have any questions about EOBs you received for claims from our office, please let us know by filling out our contact form. Thank you!

Determining Patient Responsibility

This is the third in a series of posts about the insurance claim filing process. The process can be daunting and seem confusing, but the basic components are fairly easy to understand if you break them down individually. The goal is to help our patients, and everyone else, understand what is actually happening “behind the scenes” when you use your health insurance. You can read the rest of the series by clicking on the link headers at the bottom of the post.

Read moreDetermining Patient Responsibility

Basic EOB Terminology

This is a breakdown of the major sections contained in the Explanation of Benefits letter you receive after a medical provider files a claim to your health insurer for medical services provided. More in depth breakdowns of specific terms will be included in future posts on this topic as we finish out the series (outline below).

  1. Subscriber Information:

This is basic identification information, including the name of the policy holder, type of plan, and member identification number of your insurance policy.

Read moreBasic EOB Terminology

What is an Explanation of Benefits letter?

This is the first article in a series about the Explanation of Benefits summaries that the patient receives after their provider files a medical claim. To read the rest of the series, please check out the links below.

What is an Explanation of Benefits letter?

Whenever you receive medical services and your provider files a claim with your health insurance, you will receive an Explanation of Benefits (EOB) letter in the mail from your insurer a few weeks after your appointment. If you are enrolled in an online membership account with your insurer, you may receive your EOBs electronically, instead. The EOB is an itemized statement of the claim filed on your behalf by your provider and gives a detailed summary of the amounts that are required to be paid by the patient. This summary includes all negotiated discounts and reflects the amount still outstanding after the insurer has processed the claim and assigned whatever insurance policy benefits the patient has through their insurance plan. This letter is meant to make sure that the patient is aware of the charges that have been filed on their behalf, thereby decreasing medical fraud and making patients aware of the true costs of their medical care.

Read moreWhat is an Explanation of Benefits letter?