TMA Program Helps Physicians Recover Unpaid Claims

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Medical Economics Feature – June 2011


Tex Med. 2011;107(6):37-39.

By Ken Ortolon
Senior Editor

In 2008, UnitedHealthcare (UHC) began denying a large number of claims filed by Grand Parkway Pediatrics in Sugar Land on grounds that the claims were not filed on time. 

Kay Berry, office manager for the small pediatric practice that includes three physicians and one nurse practitioner, says the issue frustrated her for months. 

"When we started having this problem, they would send a denial saying we didn't file timely, but I could always prove that we did file timely," Ms. Berry said. 

Some claims eventually were paid but others were repeatedly denied even though Ms. Berry says UHC acknowledged receiving the claims. Taking the issue to the Texas Department of Insurance did not help much because most of the claims involved self-funded plans administered by UHC; those plans are exempt from state insurance regulations under the federal Employee Retirement Income Security Act. Eventually, Grand Parkway Pediatrics had more than 300 denied claims. 

Finally, after the issue dragged on for more than a year, Ms. Berry's boss, Michael Bishop, MD, suggested she file a Hassle Factor Log® complaint with the Texas Medical Association's Payment Advocacy Department. Payment Advocacy staff researched Grand Parkway Pediatrics' claims problems and contacted UHC with evidence that the claims should have been paid. 

Ms. Berry says it wasn't long before UHC contacted her and the problems were cleared up. Early this year, the practice received more than $32,000 in payments for the backlog of claims. 

"It took a long time to get them to pay those claims," Ms. Berry said. "Undoubtedly, what TMA did to help us was much appreciated because that is what got the ball rolling." 

The Grand Parkway Pediatrics case is one of several recent cases in which TMA's Payment Advocacy staff were able to help member physicians resolve payment issues with a number of health plans. In fact, just since 2009, TMA's Hassle Factor Log program has helped physician practices across the state recover more than $1.1 million in unpaid claims, including more than $706,000 already in 2011.

TMA leaders say the Hassle Factor Log is an important tool that any TMA member can access. 

"The fact that this process is capable, very easily, of bringing the entire weight of the TMA to bear for any individual member's problem makes it very valuable for the entire membership," said Oscar W. "Skip" Brown, MD, former chair of TMA's Council on Socioeconomics, which oversees the program. 

Even the health plans seem to value the service. Robin Eldridge, UHC director of provider relations, says working with TMA to resolve physician complaints is an important tool in helping the carrier maintain good relationships with the physicians in its network. 


Getting Hassled

Genevieve Davis, director of TMA's Payment Advocacy Department, says the Hassle Factor Log is a free benefit available to any TMA member. The Payment Advocacy Department receives about 50 hassle complaints a month, she says. 

Filing a Hassle Factor Log complaint is easy. Physicians can find the Hassle Factor Log complaint form on the TMA website. They can print the form, fill it out, and mail or fax it to TMA's Payment Advocacy Department; or they can file the complaint form online. 

Either way, supporting documentation must be mailed or faxed to TMA, along with a completed business associate agreement authorizing TMA to act on the physician's behalf. That agreement, as well as a user's guide explaining all the details of the Hassle Factor Log program, also can be found on the website. 

A TMA reimbursement specialist researches each claim to determine if there is a coding or billing issue at the physician's practice that needs to be corrected or if there is a problem with the carrier. 

If it's the former, TMA reimbursement specialists send educational materials to the practice to help them learn how to avoid the same mistake in the future. "Or, if the practice did everything correctly and there's obviously some issue at the health plan, then we will reach out to our contact with the health plan to ask for assistance," Ms. Davis said. 

In the case of Grand Parkway Pediatrics, Ms. Davis says the practice sent proof of timely electronic filing multiple times without success. TMA contacted UHC's provider relations staff. UHC sent a representative to the practice to review their data, researched it, and discovered the claims should have been paid. 

Most of the claims were for evaluation and management codes for fairly small amounts, but with more than 300 claims involved, it added up to a substantial sum. 

"Then UnitedHealthcare even took it one step further and found additional claims outside of the ones the practice had found for other physicians in the practice," Ms. Davis said. "They went ahead and included those claims in the settlement agreement they offered to the practice." 


Where's the Injection?

In another recent case, TMA helped Cancer Specialists of South Texas recover more than $28,000 in claims from Blue Cross and Blue Shield of Texas for a patient who was receiving expensive injections for treatment of hypogammaglobulinemia. 

Michelle Robbins, insurance clerk for the three-physician practice based in Corpus Christi, says Blue Cross repeatedly denied payment for the injections, which cost between $3,700 and $7,000, depending on which drug is used. 

Eventually, the patient was forced to go to a local hospital for the treatments, which Blue Cross did cover. But that cost even more because the patient was admitted to the hospital to receive those injections, Ms. Robbins says. 

Ms. Robbins says she used the TMA Hassle Factor Log in the past and didn't hesitate to contact TMA again. TMA resolved the issue quickly. 

TMA reimbursement specialist Erin Gregorcyk Smith reviewed the case. She says it was clear the woman's Blue Cross coverage should have paid for the immune globulin injections whether they were administered at a hospital or in the physician's office. She contacted Blue Cross, which agreed to pay for the injections. 

Ms. Robbins says her practice not only got paid for the previous injections, but also was authorized to provide treatment for that patient for another year. 

TMA also recently aided an Austin orthopedic surgeon who had joined a local orthopedic surgery practice but was having trouble getting TrailBlazer Health Enterprises, the Medicare carrier for Texas, to approve his Medicare enrollment application. TMA helped expedite that application and cleared the way for Medicare to pay $45,000 in outstanding claims. 


Getting Proactive

While the Hassle Factor Log program might seem adversarial, Ms. Davis says many of the health plans actually like the program because it helps them identify provider issues of which they were unaware. 

"In the past, a lot of the health plans' ultimate goal was to fix that one problem [identified by the Hassle Factor Log] and not dig down and see if maybe it was a system-wide problem," she said. "A lot of carriers now are being a lot more proactive." 

UHC, for example, has revamped how it handles claims issues, Ms. Davis says. 

Ms. Eldridge says three "physician advocates" investigate physician complaints and try to determine if they are the result of physicians' billing mistakes or errors by UHC. She says they try to respond to every Hassle Factor Log complaint within 10 days and follow up with both TMA and the practice. If the issue can't be resolved in that time, they will contact both TMA and the practice to let them know where the issue stands. 

Ms. Eldridge says resolution of these issues results in physicians getting their claims paid in about half the cases. "It's a wash," she said. "There's a 50-50 chance that it's an error on our part, and we need to make some adjustment on our side. And then in other issues, it's a matter of physician education [to insure proper billing]." 

Either way, she says the program has been valuable in helping UHC improve its provider relations. "Going through TMA gives us another avenue to reach out to those physicians and build those relationships," she said. 

Dr. Brown says the Hassle Factor Log also gives the association a powerful tool not just to resolve individual physician's claims problems but also to address larger issues that might arise with a health plan. 

"The accumulation of data from the Hassle Factor Log enables the council – and the TMA Board of Trustees, if needed – to be aware of trends demonstrated by various payers as negotiations proceed to resolve various problems that members experience with payers," Dr. Brown said. "This creates a very important database to use in negotiations to argue for physicians at council-payer meetings each year." 

  Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


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