Give Payers What They're Not Expecting
Using some creative tactics can keep more of your time and money from vanishing.
By Gil Weber, MBA, Consulting Editor

While it may be your practice administrator who fights these battles day to day, he or she is fighting for your money, and using valuable time that could be better spent on practice progress. Often times, trying to deal with health plan staffers means unanswered letters and phone calls, or rubber-stamp reviews no more enlightening than the "mumbo-jumbo" originally included with a denied claim. Sadly, many plan staffers really aren't all that interested in your problems. You're just one issue on a long list of problems that they either can't or won't address.

And so creative practices often find nontraditional means to achieve their ends. They find a back door to the solution, or they create a door where none existed. Here are some of their stories.

Review should mean review by a peer

Michael Lockard, from Talley Medical-Surgical Eye Care Associates in, Evansville, Ind., was fed up with claims and surgical authorization requests being denied by people with little or no understanding of ophthalmology. He's come up with an effective means to achieve desired results.

"Many times we send items to commercial carriers for review, and typically they're denied. We know that if someone with an ophthalmology background had done the review, the medical necessity in question likely would not have been challenged. Many of these cases are pre-authorizations reviewed by case reviewers who have a CPT book and an ICD-9 manual with a list of corresponding treatments, but little or no understanding of the subtleties inherent in ophthalmology.

"I've had good success resolving denials by inserting two carefully worded paragraphs into my letters. These paragraphs now go along with all of our review cases, both for pre-authorizations and for post-claim denials. They show the health plan, the patient, and the Department of Insurance that we are making a request for review by someone who understands medical necessity specifically as it relates to ophthalmology.

"The paragraphs are:

'If you do not believe the enclosed information establishes medical necessity, please provide me with your detailed rationale based upon the standard of care, the specialty of the physician-advisor who reviewed this case, and whether he/she is Board Certified.

In conclusion, we are requesting an expedited review of this case by a Board Certified, clinically practicing, specialty-matched physician-advisor who will make a decision based on the standard of care. This would meet the medical review standards of nationally recognized authoritative review organizations, applicable state regulatory agencies, and recent appellate court decisions.'

"One recent success we had using this specific language was in the case of an MRI referral for a child who had a suspected vertical nystagmus. Because a confirmation of the vertical nystagmus could point to a potential brain-stem lesion or tumor, an immediate MRI was necessary. The commercial carrier refused to authorize the MRI, stating it was not necessary. We sent a letter with the above language to the carrier with a copy to the State Department of Insurance, another to the patient's parent, and another to the parent's employer (with mom's permission, of course).

"We shipped the letter via overnight courier to the plan's medical director. The next day, after verifying with FedEx that the package had been delivered, I called the plan asking for resolution.

"At first I was told that they had not received the request. But when I stated that FedEx showed the time the package was received and the name of the person who received it, I was immediately transferred to a nurse reviewer. After much discussion, during which I specifically explained that denial of this MRI could have serious and dire consequences for the patient, the MRI was approved.

"I used this approach in another case involving LASIK for a patient with severe anisometropia. The 49-year-old patient had previously undergone cataract and YAG surgeries, and a scleral buckle for a retinal detachment. The buckle clearly caused the anisometropia, which was uncorrectable with glasses. Further, the patient was contact-lens intolerant.

"In our surgeon's opinion, LASIK was medically necessary for the patient to be able to perform daily activities. I sent a letter with the above language to the plan, and it actually sent the review to an outside physician, who agreed with our reasoning. The LASIK was paid as medically necessary under the patient's benefit plan.

"The bottom line for us is to request a review by a physician who is suited to review an ophthalmology claim. By doing so we can feel as if our request is supported if we have to argue further appeals with a carrier."

Laurie Sanchez, COE, is practice administrator at Brandon Eye Associates in Brandon, Fla. The state of Florida has a long history of frustrating and sometimes contentious dealings between providers and payers. So, Florida practices know that getting things done takes persistence and creativity. The case Laurie related involved an HMO that represented about 5% of the practice's business.

"For some time, things had been going relatively smoothly. We had the referral and billing process down pretty well, and revenue was coming in at a steady pace. Then the bottom dropped out.

"Our surgical scheduler told me that she was unable to schedule any patients from this HMO with the surgery center, and that effective 30 days ago the surgery center was no longer on the plan! I called our Provider Relations contact at the plan to verify this surprising information. She had no idea what was going on, but promised to look into it.

"A week passed, there was no response, and the backlog of surgical cases was building. I again called our contact. She assured me that she was working on the problem and would call me back. This was December, holiday time, so 2 more weeks came and went with still no call and no solution.

"January arrived and I was determined to get to the bottom of the matter. Luckily for me, the surgery center's administrator came by my office for a PR visit. She had no idea what was going on but assured me she would look into it. I gave it 2 more days and then took matters into my own hands.

"I called the surgery center and spoke to the scheduler. She informed me that it was the center management's decision not to schedule the plan's patients. The HMO owed $31,000 for back claims, and the surgical center had exhausted all efforts for reimbursement. Apparently someone at the HMO was telling the surgery center that they were billing for cataract surgery using the wrong code. And the HMO wanted the surgery center to resubmit all claims with operating notes!

"The scheduler had the name and number of the person who was telling her this. He was one of the plan's head managers. I called his direct line and left a message on voice mail asking him to call me so we could resolve the issues. Not unexpectedly, he never called back.

"Two days later I sent him a letter, stating that the code the surgery center was using was correct. I also told him that I did not have an intelligent response to give to his plan's patients and their primary care physicians when they asked why we could not schedule their surgeries. And I told him that I was going to give the patients and PCPs his direct phone number and have them call him.

"I sent a copy of this letter to his boss (the CEO of the HMO), to the local hospital CEO (the hospital owns the surgery center), and to the surgery center. Within 2 weeks I was at a meeting with this individual and everyone else who was cc'd on the letter.

"Evidently the pressure from patients and primary care physicians got the attention of the plan's 'higher-ups.' And it obviously annoyed the manager who had been barraged with irate phone calls. Very quickly the surgery center started receiving payments. We can now schedule and perform surgery on the HMO's patients, and all is well.

"We've found that sometimes you have to put pressure in the right places to get results. And sometimes you have to use your patients and primary care physicians as leverage. Patients, especially, are a great resource. And the HMOs know it."

North Carolina has not had a particularly high HMO penetration rate, but it has had its share of unpleasant experiences with ophthalmic carve-outs poorly managed by third-party administrators (TPAs).

One practice, whose administrator requested anonymity, was having problems with a TPA that seemed uninterested in addressing its concerns. The administrator creatively solved the problem by "bringing the mountain to Mohammed."

"We are involved in an optometric/ophthalmic carve-out for two key health plans in the area. All claims are adjudicated by a TPA. We had the choice of providing both vision and med/surg services but opted for only med/surg.

"From the beginning, working with this TPA was a nightmare. Not only were the reimbursements horrible but, as a result of numerous, preventable problems, our administrative costs were through the roof. We could've had a full-time person devoting 100% of her time to these claims and still we'd have been behind.

"Claims were denied for every reason you can imagine. For example:

• denied as routine vision care when there was a clear medical diagnosis (Then, when we refiled the claim, it would be denied again because the claim filing period has passed.)
• denied due to no Medicare EOB attached even when we had proof that the TPA had received the claim three times with an EOB attached
• denied stating there was no referral. (Then, when the TPA admitted the referral was there, the claim was denied again as being past the claim-filing period.)

"And we were continually caught between the TPA and the plans, each claiming that the other was at fault for nonpayment. Many times we complained to a plan only to find out that the TPA had, indeed, received a check several months earlier but had failed to pass the funds on to us.

"Basically, on more than half the claims we submitted to this TPA, some follow-up was required to chase down reimbursement. Sometimes it took days to get through all the unpaid claims on the EOBs.

"Probably the worst part was the feeling of utter frustration with the futility of our efforts coupled with the absurdity of the TPA's rubber-stamp appeals process. We were extremely diligent about sending clean claims, but when an appeal was necessary it typically went nowhere. We'd appeal a denied claim with the reason why it shouldn't be denied, and then we'd get back the same reason for the second denial!

"This craziness went on for several months. Though we had been given a rep to work with, that person changed almost monthly. So, to move things along, I decided to initiate a two-pronged attack. First, I got the patients to go to bat for us. When we received incorrect payments, per the TPA's instructions, we billed the patients. When angry patients called us, we assured them that we understood their anger and the fastest way to get the mess cleared up was for them to call the plan and complain. One thing insurance companies don't like is unhappy subscribers.

"I also started calling our provider rep each time a claim was improperly denied. He finally got sick of my constant calls. Eventually, he agreed that our insurance coordinator and I should go to his facility, and that we'd all work together on these outstanding claims. I took my laptop computer and several of us sat down in a large room and went through each outstanding claim. This way they could look at each charge and see how many times we had filed, when we filed, to whom we talked, etc.

"In the end, we had the proof we needed, most of the claims were paid, and we still have a good working relationship with the plan."

Winning friends and influencing people

Keith Slater, MBA, is administrator at Baptist Eye Surgeons in Knoxville, Tenn. Keith received notice of what would be significant reductions in compensation from a major commercial carrier with HMO, PPO and gatekeeper PPO contracts. His way around the reductions turned on the suggestions of an unlikely ally, a manager at the health plan.

"We were notified by the carrier that there were going to be a couple of revisions to our existing commercial contracts, including some changes to the fee schedules. I checked to see how the changes would affect our 20 most commonly used CPT codes. My analysis revealed that the reductions would be severe: The 20 codes would end up equating to roughly 100% of Medicare under this new fee schedule.

"Initially I called a provider relations contact at the plan to express my concerns. Although she was sympathetic, she said there was nothing she could do. I sent her a formal letter restating my concerns. At about the same time, I learned that the provider relations department had a new manager.

"Another ophthalmic administrator and I welcomed the new manager to the area by taking him to lunch. During lunch we gave him the rundown on our specialty and the general state of managed care in eastern Tennessee (e.g., all other major commercial payers were reimbursing at or above 130% of Medicare). We discussed nonbusiness issues, such as neighborhoods, schools, and outdoor recreation activities.

"Simultaneously, I presented the upcoming fee changes to my nine physicians and was given permission to drop this plan if necessary. This was a difficult situation because this plan was our biggest commercial payer by far. To make matters even more difficult, at the same time we also elected to pull out of another major commercial payer. Terminating both contracts would mean losing about 10% of our business.

"But I explained to our physicians that agreeing to the proposed reduced payments with the market leaders would equate in the very near future to being reimbursed by all commercial carriers at roughly 100% of Medicare. That was a disaster in the making.

"Then came the twist that makes this story so atypical. The provider relations manager predicted that if I turned in a 90-day written notice of our intention to terminate the plan, the plan's higher-ups might relent and give my group a modified contract (realizing that we were not making an idle threat to terminate). He added that he'd do what he could to help, and I took that as something of a "nudge" for us to make our move. (Our discussions also led me to believe that several other large groups in the area -- orthopedics, general/vascular surgeons -- were about to pull out, so it seemed as if time and circumstances were right.)

"I gave notice and also called the manager to ask whether the plan would at least give us 130% of Medicare on our top 20 codes. A few weeks later he called and said they would give Baptist Eye Surgeons 130% of Medicare on our top 20 codes for the HMO and PPO gatekeeper plans, provided we agreed to stay as providers on the PPO plan (at the unacceptable reimbursement schedule).

"Fortunately, the plan was rolling its PPO enrollees into the HMO and gatekeeper PPO plans in the near future, so that part of the reimbursement issue became moot. I agreed; he drafted a new agreement; and we signed.

"Everyone's happy and we've solidified our relationship with this payer -- at a reimbursement level that works for our physicians."

Stop taking "no" for an answer

As these cases illustrate, challenging issues with third-party payers call for creative solutions. And determined practices who push, prod, and cajole until "no" becomes "yes," are the ones who can sooner return to their main focus of caring for patients.

Gil Weber, Ophthalmology Management's Consulting Editor, is a nationally recognized author, lecturer and practice management consultant to practitioners and the managed care and ophthalmic industries, and has served as Director of Managed Care for the American Academy of Ophthalmology. You can reach him at (954) 915-6771, gil@gilweber.com  or at www.gilweber.com.