What to Do When You're Denied Compensation

Optometric Management, Jul 2004 by Weber, Gil

Contact and use your instrument suppliers (they have the latest research and clinical test data), state and national societies (as your professional advocates), state and federal legislators (especially those on healthcare committees), patients (insurance companies don't like to hear from disgruntled members) and employers (insurance companies also don't like to hear complaints from their customers).

Still, assuming the payer won't pay despite your best efforts to "educate," you're forced to look to the patient for payment, and that's the second side of this bifurcated approach to payment. To determine the proper protocols and your right to pursue the patient for payment, go back to the Provider Agreement. It should contain statements about covered and noncovered services and, hopefully, a definitive assertion that you may collect payment from a patient for any services not covered by his insurer.

The Provider Agreement may also contain some preconditions to billing and collecting from the patient. I described the most common earlier (i.e., informing the patient in advance that his benefit plan doesn't cover the service and obtaining in writing the patient's acknowledgement of financial responsibility).

Many payers take the position that if you don't get the patient's signed agreement in advance then you're out of luck afterward. But at least if the Provider Agreement and/or a Provider Manual (which has been incorporated by reference) documents your right to bill the patient, then you're on the correct path.

When it gets really ugly

Now what happens when a plan states that it won't pay for a service because it deems the care not medically necessary or "experimental" as Aetna does with 92135, and you're also told you can't bill the patient - perhaps despite verbiage in the Provider Agreement that you can bill for noncovered services? Does the plan instead expect you to fall back to an older, less sophisticated technology - in this case one that may not provide the early detection and confirmation capabilities of SCODI? Or does it expect you to provide the "experimental" service for free, without compensation from either the plan or patient?

To provide the best possible care and be compensated for 92135, what must you do to improve your chances of collecting when the plan won't pay?

* Get every commercial insurance patient to sign a consent form up front (in case the payer deems something noncovered). The safest, short-term tactic is to have every commercial insurance patient sign a document you create that's similar to Medicare's Advanced Beneficiary Notice (ABN). This document causes a patient to acknowledge that if his insurance doesn't cover the service or procedure for any reason then he accepts financial responsibility. (Get your attorney's guidance on the exact wording so as not to conflict with federal or state laws or other contractual language.)

* Amend current and future Provider Agreements. You'll eliminate all sorts of hassle if you can get a plan to remove the contract language requiring your practice to get a patient's prior written agreement to pay for any services deemed noncovered by the payer. Some plans will agree to this (although they certainly won't volunteer that willingness, so ask).