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Acadia Benefits Inc. Blog

  • The Importance of Timely Filing For Claims Paid in Error

    Posted on November 9, 2016

    As we head into a new benefit year for many of our customers, it may be a good time to remind people about the importance of using the correct ID card during the transition time.

    There are occasions where the new ID card may not have been received by a member. In addition, their “old” ID card may not be terminated right at the beginning of the year.  For example, for a January 1 renewal, the new group may still be in the process of being set up, and the former ID card has not been technically cancelled yet.

    A member may be at the pharmacy on January 2nd, and their old card runs through with no problem.  A member may think they are all set, because the Rx ran through. However, the carrier will eventually catch this error in payment, and will send the member a bill for the cost of the Rx that was filled in error.

    If members receive one of these bills asking for the payment to be refunded, it is important to act quickly and not ignore the bill.  There is a window of time to submit to the new carrier (known as “timely filing”).

    If a member misses the filing deadline for the claim, it will be denied by the new carrier and the member will end up responsible for the entire bill.

    Therefore, if you do receive a bill for a claim paid in error, please call your new carrier ASAP to discuss how to submit this to them for processing.  Acadia Benefits is also here to help should any of our customers experience this issue.

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  • Tips from Paula: Establishing A Relationship With Your PCP

    Posted on July 6, 2016

    During our open enrollment presentations, and here on our blog, we often remind our customers of the importance of wellness exams with their Primary Care Physicians (PCPs).  The benefits of these wellness exams are not just health-related.  We are finding more and more that it is extremely important for patients to establish a relationship with their PCP up front, and not wait until services, referrals, or prescriptions are needed.

    For example, many doctors will not write a prescription refill if they have never met the patient. They may also deny writing a referral to a specialist without seeing the patient first.  Conversely, if the patient has a good relationship with their doctor, and the doctor knows their background and history, they may be amenable to waiving the need for an office visit before they will refer a patient on to a specialist.

    Therefore, we strongly recommend that patients book that annual exam with their PCP every year. Not only is it covered in full under the Affordable Care Act, but it will begin to build that necessary doctor/patient relationship for the future.

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  • Know Who Your Vision Carrier Is

    Posted on May 2, 2016

    As benefits advisors, we are always looking for ways to find the best benefits for our customers.   Consequently, we may offer new and innovative ways for employers to cut costs, while still offering plans with viable coverage.

    One of those changes may be seen in vision plans. In the past, several carriers would offer routine eye exams and discounts for hardware embedded into their medical plans.   Members would simply present their medical ID card to the eye doctor’s office, and everything was filed and processed with the medical carrier.

    There are now several separate vision plans being presented to our customers. One example is the Blue View Vision (B.V.V.) plan, through Anthem Blue Cross. Blue View Vision uses a separate network of providers, separate claim forms, ID number, customer service number, etc. In this case, it is very important that members not use their Anthem medical card when obtaining eye care. They should present their Blue View Vision card and ask the provider to bill accordingly. If the provider is not in the B.V.V. network, the patient will have to file the claim themselves.

    By not following this procedure, claims will be held up and consequently denied by the medical side. It is important to note that claims not automatically forwarded by Anthem medical over to Blue View Vision.

    As always, we strongly recommend that employees know and understand their benefits before obtaining services.

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  • Tips from Paula: Billing for DME Items

    Posted on February 2, 2016

    When we are having surgery or other services that are performed by a doctor or hospital,   there are times when medical supplies, also known as Durable Medical Equipment (DME), are dispensed by that doctor or hospital. We should not assume that the doctor or hospital is the actual vendor for those supplies.

    For example, if a person has surgery at an outpatient surgical center, they are often sent home with items such as a walker, crutches, or specialty ice packs. We might assume these items will fall under the general bill from the center, along with the other services, such as the surgery itself, surgeon fees, etc.

    However, we are finding that surgical centers are not always the actual vendor for many of these DME items. They may dispense them, but the bill for these items will come from a third party. And with that third party billing, there are often problems with coding and coverage once the claim hits the insurance carrier’s claim system. If the provider submits with a code that the claim system doesn’t recognize, the claim will deny.

    The vendor may also not be considered “in network”, which, for some plans, can result in higher out of pocket costs for the patient.

    Members should be prepared to review their bills and statements from the carrier. They may always dispute this via the appeal process with the carrier, and/or work with the provider to ask them to submit with a code that the insurance company can recognize.

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  • Tips From Paula: Third Party Reviewers for Imaging Tests

    Posted on November 6, 2015

    As patients, we are often referred by our doctors for high-tech imaging tests, such as MRI, CT Scan, and PET scan. While the doctor may feel these tests are necessary, we must remember that these tests are very expensive, therefore, most insurance companies require a “prior authorization” before they will cover the tests. Most have contracted with a third party reviewer – a company whose mission is to review each case for medical necessity.

    The process usually starts with a request form that is faxed to the third party reviewer.   The clinical staff person reviews the request and makes a decision on coverage. Communication for the approval or denial is sent to the requesting doctor at this point. If the test is denied, the provider is guided to file an appeal for coverage. The fastest way for a doctor to appeal is to call the third party review company and speak, “peer to peer”, with another clinical person. During these calls, questions are asked, and medical updates are easily shared. It gives the doctor a chance to make their case by actually speaking to someone, vs. faxing forms or medical records. The decision to approve or deny is usually made by the end of the call, giving the doctor and patient more time to plan the next step in treatment.

    If patients experience delays in getting answers about their high-tech imaging requests, we recommend they call their doctors and ask that the peer-to-peer phone call be made ASAP.   Most doctors’ offices have the phone numbers to call and should be familiar with the procedure.

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  • Tips from Paula: Providing ID Card Information to Ancillary Providers

    Posted on September 24, 2015

    In the health care industry, the term “ancillary provider” refers to providers who are not the actual treating physicians or hospitals. An ancillary provider could be a lab, imaging company, or medical equipment supplier, to name a few.

    When our doctor sends us for these types of services, many times our insurance ID card information does not “follow” the order for the services. For example, if our PCP determines in an office visit that an x-ray is needed, and the x-ray facility is not in the PCP’s practice, the ID card info that we provided when we checked in for our PCP visit is not always sent along with order for that x-ray.

    Therefore, we may receive a bill from the x-ray company, saying the claim is not paid. The reason for this non-payment is not always printed on the bill, so we often assume the insurance company has denied the claim, when in fact, the claim was never sent to the insurance company.

    We recommend that our customers first call the provider billing office to be sure they have the insurance information on file. If not, the next course of action is to provide all the information on the card (perhaps fax or email a copy of the card to them), and ask them to submit to the insurance company for processing. Once this is done, a new statement should be generated showing the processing of the claim.

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  • Tips from Paula: Confirming Network Status

    Posted on July 10, 2015

    Most of us work very hard to get the most out of our benefits. That includes checking the network status of our physicians, hospitals, ancillary facilities, etc.   We have also become quite astute in using carrier websites to check those network statuses.   It’s important to never assume a physician who is part of a contracted, in-network hospital, is automatically contracted themselves.

    For example, a hospital may show up on a carrier website as a participating provider. We may then make an appointment with a physician who is affiliated with that hospital, assuming they must be participating as well. This could result in a claim not being paid, or it may be paid at a much lower level of benefits.

    Therefore, when checking online for a provider, always search for the individual provider’s name, not just the hospital they are affiliated with. If one is unsure, a quick phone call to the member services phone number on the back of their ID card will also provide a fast and accurate answer.

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  • Tips From Paula: Keeping Your Personal Information Updated With Your Insurance Carriers

    Posted on May 19, 2015

    When we fill out our application forms for insurance coverage for medical, dental, disability, etc, we are asked various questions about our personal information, such as address and telephone number.   This is important to keep updated, since the carriers do reach out from time to time to discuss claims and eligibility issues.

    For instance, a member may be out on disability, and the carrier needs to reach them to inquire about a missing medical record. If the phone number they have on file has been changed, the carrier has no way of reaching the individual. This may result in delays in processing that all-important disability check. The same goes for a medical plan.   ID cards are sent out from time to time, as well as information on changes to the benefit plan. The carrier cannot track down the large volume of returned mail, and in turn, the member may not be receiving important correspondence.

    Updating your personal information may be accomplished with a quick phone call to the number on your insurance ID card.  Your employer should be notified as well.

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  • Tips from Paula – Prior Authorization for Medication

    Posted on February 25, 2015

    Many times, we find ourselves at the pharmacy trying to fill a prescription, when we hear the words, “It’s not going through – denied for prior authorization”. Some may wonder why a drug would require prior authorization, when the doctor already wrote the prescription. Isn’t that “authorization” enough?

    In many cases, a prior authorization is often necessary to try to save costs, however, it is sometimes needed to be sure the drug is right for the patient.

    If a drug needs approval, either the patient or the pharmacist will need to let the doctor know. The doctor might switch the patient to another drug that doesn’t need prior approval. Or, they can contact the insurance company’s Pharmacy Help Desk to start the approval process. Approval for some drugs requires an actual form to be filled out and faxed in, others can be authorized with a simple phone call between the doctor and the Pharmacy Help Desk.

    It is always a good idea to follow up with the doctor’s office staff to see what their normal turnaround time is for these types of requests. If the need for the drug is urgent, that should be communicated to the physician’s staff as soon as possible.

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  • Tips from Paula – Coding for Colonoscopies

    Posted on January 23, 2015

    As responsible health care consumers, many of us know that getting our annual check-ups and other routine services is very important for our overall health.  One of the most common routine tests for those 50 years old and above is the screening colonoscopy.  In addition to this test being mandated at 100% coverage under the Affordable Care Act, for those of us residing in the State of Maine, there are extra measures put into place meant to save us out-of-pocket costs.

    A few years ago, Maine adopted legislation that requires all colonoscopies booked as routine/screening, must be coded as routine/screening, regardless if a medical condition was found during the test.  For example, if a member, aged 50, has their first screening colonoscopy, and a polyp is found during that test, the provider must still bill the procedure as routine/screening, and NOT with a medical diagnosis.

    In addition, once a polyp is found, it must be sent to pathology to be tested. What many people do not realize is that that particular service must also be paid as a routine/screening procedure, in other words, at 100% coverage along with the rest of the exam.

    Many times, the pathology claim will be sent to the insurance company separately than the colonoscopy claim itself.  Oftentimes, it is from a totally separate provider from where the colonoscopy took place.  Insurance companies don’t always automatically “tie” the two claims together, and may impose cost sharing such as deductible and/or coinsurance.    If members receive a bill for pathology services related to a routine colonoscopy, they should call their insurance company right away and ask them to reprocess the claim as routine/screening and to be paid at 100%.

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