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Acadia Benefits Inc. Blog

  • Tips from Paula: Understanding your lab work benefits

    Posted on June 7, 2017

    As the Employee Advocate here at Acadia Benefits, I get several calls each month from our customers who are unsure of how a claim for “routine lab work” was processed.  Because their doctor ordered this lab work as part of their routine physical, many people assume the lab work will be covered in full, similar to how the actual physical is covered.

    However, many insurance plans are set up to follow guidelines under the Affordable Care Act.  Those guidelines state that not all lab work is automatically covered in full.  There is a listing available at the following website:

    As we can see, the lab work on this list is limited. Therefore, if your doctor tells you they are ordering routine blood work as part of your annual physical, be prepared to possibly receive a bill for these services, as they will most likely be applied to the plan’s deductible.

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  • June 1st Breakfast Seminar

    Posted on May 10, 2017

    We hope you can join us for a breakfast seminar:


    Healthcare Cost Reduction Initiatives

    and ERISA Compliance Considerations:

    Tips for 2017 Open Enrollment


    Thursday, June 1st

    7:30 – 9:30AM


    Pierce Atwood, LLP

    254 Commercial Street

    Portland, ME 04101



    With the move away from fee for service to value based reimbursement initiatives, employers still struggle with healthcare costs and the shift towards high deductible health plans. Further, employers looking to bring added value to their employee benefits offerings may be doing so at the expense of ERISA compliance.

    Join our expert panel for a discussion on recent trends in health plan design and contracting to address healthcare costs and population health management, as well as tips and traps for employers offering voluntary benefits.

    Mike Burton from Acadia Benefits will be presenting along with John Larrabee from Harvard Pilgrim and Pierce Atwood Attorneys Christine Worthen and Byrne Decker.



    Please email Sara Pinto at to RSVP to this event.

    We hope to see you in person, but if you can’t make it in and would like to attend remotely, please let us know.

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  • Tips from Paula: Who is Responsible for Obtaining Referral Extensions

    Posted on January 31, 2017

    Over the years, patients on HMO plans have learned the importance of obtaining referrals. What we need to remember, however, is that referrals are often written for a certain number of visits, or for a specific time frame. For example, a PCP may write a referral for a patient for three visits to an orthopedic specialist.    Once those three visits are up, it may be up to the patient to check in with the PCP for more referral visits, if necessary.   A good specialty practice may pick up that the number of authorized referral visits have been used up, but we should never assume this will happen. In addition, referrals are not “automatically extended”.  Therefore, it’s up to the patient to pay strict attention to their referrals, for time frame and/or number of visits allowed, and be proactive in following up for new referral visits if necessary.

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  • 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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