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Acadia Benefits Inc. Blog

  • 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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  • Tips From Paula – Incomplete Claims

    Posted on November 24, 2014

    In the ever-changing world of health care, providers are often overwhelmed with the amount of paperwork they must file. One of the most important documents they file for patients is the Claim Form.

    If a claim form is not completely filled out, i.e., if a field is left blank, or if there is incorrect information filled out (such as date of birth, ss #), the claim will most likely not process. Unfortunately, many times the insurance company does not reach out to the provider to request the missing or correct info. As a result, the claim is left in a “pending” state. In the meantime, the patient assumes all is well, until they receive a bill from the provider showing that nothing was paid on their claim.

    Patients often assume the insurance company has denied the claim, not realizing it can be related to the scenario described above.

    We recommend that members call their insurance company when they have an unexplained unpaid claim. If they find out it is pending for missing or incorrect information, they should call the provider’s billing office to be sure the claim is re-filed with the corrected information. Once this is done, the claim should process in a timely manner.

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  • Tips from Paula – Confirming Your Referral Is In Place

    Posted on October 6, 2014

    For many of us on plans that require referrals for specialty care, it can be difficult to know if a referral was done properly and/or if the insurance company approved the request for referral.

    Many patients assume that, if their primary care physician referred them to a specialist, it is automatically approved by the carrier. This is not always necessarily the case.

    There are times when a PCP may refer a patient to a specialist, but only in the form of a verbal referral. For example, the PCP may say to the patient, “I think you would benefit by seeing Dr. __________ for your condition”.   Patients often will leave the office, assuming that the actual referral will be done on paper, when in fact, it may not be. It is rare when this happens, but when it does, it can cause much confusion for the patient, and a lot of work trying to obtain a retroactive referral. If too much time has gone by, there is a good chance it is too late to obtain that retro referral.

    Another type of referral that must be verified is the “out of network referral”. A PCP may want to refer a patient to a specialist who is not in the patient’s network. If the patient is on an HMO plan, there will be no benefit for that specialty visit without an out of network referral approval. These types of referrals are not always approved. If the carrier can show there is another in network specialist to treat the condition, the request for the out of network provider will often be denied.

    This blog post serves a reminder to always check with your insurance company to be sure your referral has been approved. Never assume that because the PCP said they are referring you to another provider, that the referral is approved.   The best way to confirm is to call the toll free number on your ID card, and then the rep can verify if your referral is in place.

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  • Fiduciary Responsibilities under ERISA

    Posted on September 17, 2014

    Below is the link to the September 16, 2014 UBA Employer Webinar Series: “Fiduciary Responsibilities under ERISA”

    The Employee Retirement Income Security Act (ERISA) lays out the definition and responsibilities of Fiduciaries. Individuals who oversee employee benefit plans need to understand these requirements. In this webinar we will cover:
    • How a person becomes a fiduciary
    • The duties of a fiduciary (selecting and monitoring service providers, making sure contributions are made on time, providing required disclosures to plan participants, etc.)
    • The importance of creating and following procedures
    • The critical need to read and follow the plan
    • Potential consequences of mismanaging fiduciary responsibilities
    • Ways to manage fiduciary duties and risks
    • Recent developments with fiduciary obligations
    The webinar will focus on group health plan issues, but will also touch upon some of the additional issues that fiduciaries of retirement plans need to consider. As Department of Labor audits of benefit plans become more commonplace, this is a must-see webinar for anyone tasked with overseeing employee benefits.

    Randal M. Limbeck, Shareholder – Jackson Lewis P.C.
    Randal M. Limbeck is a Shareholder in the Omaha office of Jackson Lewis P.C. He specializes in representation of clients in the areas of ERISA, employee benefits, and executive compensation. Mr. Limbeck has represented clients in a broad range of industries and size, with respect to design, document drafting, employee communications, litigation, and assistance in dealings with the IRS and Department of Labor.
    * * * * * * * * * * * * *
    Please feel free to watch/listen to this whenever it is convenient for you and your staff. It will be available for you to view for the next 11 months. Your name and email are required for registration. There is no cost however this webinar has been approved for one credit hour toward PHR, SPHR and GPHR recertification through the HR Certification Institute. Once you have viewed the webinar, the last page will provide details on receiving the credit hour.

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  • Tips from Paula – The Appeal Letter

    Posted on September 11, 2014

    As health care consumers, there are, unfortunately, circumstances in which we find that our claims have been denied by our insurance companies. Members must keep in mind that it is their right to appeal these denials. While some appeals are the responsibility of the provider (i.e., a hospital did not obtain prior approval for a surgery), this blog will review the steps for a member appeal.

    If a claim is denied, the patient will be informed in writing by the insurance company. There is usually a timeframe involved for the appeal to be submitted. It is very important to make note of this date and to submit the letter before that deadline.

    The appeal package should consist of: (1) An appeal letter written by the member. (2) A letter from the doctor and/or specialist addressing specifics of the case. (3) Any pertinent information from the patient’s medical records. (4) It may also be helpful to include any articles from peer-reviewed clinical journals that support the case and that illustrate medical necessity and positive outcomes.
    When writing the appeal letter it is important to note why the member disagrees with the denial and why they feel the procedure should be covered. It is also important to keep the letter fact-based, concise, and without emotion or anger. The letter should include member identification information, such as policy number, group number, claim number, or other information used to identify the case.

    We always recommend that members save copies of everything that is sent in for the appeal. In addition, if the package is faxed, it is a good idea to print out a fax confirmation page, so that there is a record of the fax being sent within the timeframe allowed. It may also be necessary to submit that documentation to another level if the first level of appeal is denied.

    As the Employee Advocate, I am always available to assist with appeal letter writing and review, and will also help members with coordination of materials, aa well as submission of the appeal itself.


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