Consultant’s corner: Private insurers start playing denial game

Friday, May 25, 2012

YARMOUTH, Maine – The days of HME providers having it better off with private insurers than Medicare may be over, say industry consultants.

Recently, Blue Cross Blue Shield, Aetna and other private insurers have tweaked some of their timely filing, payment and other policies, resulting in a spate of denials, consultants say.

“Providers have had more relaxed relationships with private insurers,” said Billie Jo Bowser, an associate with Lieber Consulting. “They didn’t have to worry so much about documentation, for example, knowing how much they drive doctors crazy on the Medicare side.”

The changes made by private insurers are such a big deal because providers have long used Medicare as a guideline for private insurers, but now, in some cases, they have different policies.

One case in point: For three months of diabetic supplies, providers can bill Medicare at the start of the supply period, but now they must bill some private insurers at the end of the period.

“It’s scary because, with competitive bidding, most providers want to shift their focus to private insurance,” said Kelly Wolfe, CEO of Regency, Inc. “So it’s not promising to see that they’re playing these games.”

In most cases, providers are able to get private insurers to pay up, but it takes significant legwork, more than with Medicare, consultants say.

“Medicare is an open book—if they’re denying claims, you know how to get paid with an appeal,” Wolfe said. “With private insurers, it’s really about calling and arguing, calling and arguing.

Consultants advise providers to update their contact info with private insurers on a regular basis, so they receive bulletins and other notifications of changes.

“What I’m finding is that whoever the private insurer has on file to send correspondence to is no longer there,” Bowser said.


Ok folks this is not a new trend with commercial carriers.  Private insurances have been beefing up their staff to nitpick claims for supporting documents for some time now.  There are also many who've adopted Medicare's coverage criteria for HME.  I do agree that with some companies it's a matter of calling and arguing--there are some with a notorious reputation of denying a claim for no valid reason right off the bat.  When they're called on it, they just say 'sorry, we'll reprocess that for you, which may take 30-60 days', or whatever their policy is.  It's all about delaying payment.  You'll get your money, but you wait for it--- even though the supplier is mandated to pay their manufacturers in 30 to 45 days or risk having the accounts put on hold.