Blondie and the (Medical Coding and Billing Error) Beast, Part 3: APPEAL WON!

Originally published in Tincture.

More than a month after my last update detailing Blondie’s labrum tear surgery final claims appeal filing, I received this note from her mother:

Dear Mandi and Mike,

I just wanted to let you know that D just finished a meeting with the (employer) person who deals with health insurance issues ( I don’t know the proper title.) Anyway, she said that they just got confirmation that Insurer X has recently finished reviewing our appeal and has deemed that the medical payments will start being paid to the providers! She also said that the appeal you 2 put together on our behalf included all the information that Insurer X SHOULD have received in the first place, and that the Provider X office did not include said info originally like they should have. She also told D that if we have ‘overpaid’ on our part ($$$ that should have been paid by Insurer X) then they will credit those amounts back to our payment card and it will ‘roll-over’ into 2017 for our medical needs in the next year.

I am ecstatic beyond words, and cannot wait until D gets home tonight so we can celebrate. And maybe now he can start sleeping properly too, with this huge burden off his mind.

Hallelujah! I sincerely hope this news helps D sleep at night. Getting rid of an unwarranted $60,000 debt and threatening bill collector calls should be a tremendous load off the family’s collective minds.

And yet, although the battle is won, the war isn’t over.

My initial reaction was indignation at seeing Insurer X’s response that, had this information been provided by the surgeon’s office, the original appeal would have been approved. Months ago. It wasn’t news that the provider’s office hadn’t submitted the appropriate documentation for the initial appeal; we found that out when we requested the initial appeals package, in order to prepare our own final appeal. But it’s infuriating that the ultimate conciliatory response to the waste of time and potential long-term financial consequences to this family boils down to, “Our bad.”

Still, I believe in celebrating the small victories. I responded:

That’s fantastic news, M!!! I’m so glad to hear it.

Here are some things I’d do as soon as you have the information in writing from Insurer X:

- Call every single one of the providers involved, share the news, and ask what documentation they need in order to pursue their claims.

Also, ask them to provide you with documentation about the status of the claim in their system?—?has it gone to their own internal collections department, have they outsourced it to a debt collection agency to process (and if so, get the information about that debt collector), or have they sold the debt (and, if so, get the information about that debt buyer).

- Get someone from Insurer X to walk you through (on the phone, and then have them follow up in writing with the claim detail) WHICH claims they have now approved for payment, and whether there are any previously denied claims that will not be addressed by this decision. There were more than 50 claims associated with this case, overall (including all the PT appointments)?—?is Insurer X taking care of paying all of the claims that were related to the initial surgery, or are they expecting subsequent appeals for each of the claims that were denied due to the initial denial?

Winning the insurance appeal battle is but the first step in a potentially protracted process to reverse the implications of the original errors that caused the claim to be denied in the first place. Medical debt is one of the leading contributors to bankruptcy?—?and it’s not always (quite possibly not even most of the time) because the patient didn’t have insurance to cover the costs. Medical debt follows the patient for as long as there are debt-buying entities willing to pursue them, which can be years (even decades) after the provider has closed the books?—?even if the provider eventually gets paid.

It isn’t fair. It isn’t just. But it is perfectly legal. And it is a nightmare that many (if not most) healthcare provider organizations and insurers don’t consider in their Consumer Experience or Patient Engagement steering committee meetings. It is a shadow reality?—?because it doesn’t impact the organization’s bottom line. Just the patient’s.

There is a long way to go before *I* will be able to sleep soundly, thinking about Blondie’s experience.

But there is hope that justice will prevail. I will certainly update this series with any final outcome. In the meantime, there are things we can do, collectively, to prevent this kind of situation from occurring (or, escalating to this extent).

As a patient:

1. Request documentation of *everything*, *every time* you see a provider. Ask for your complete medical record (and know that your provider MUST find a way to give it to you, by law).
2. Keep every bill you receive from a healthcare provider?—?until you receive proof that the bill has been paid in full (either by your insurer or yourself).
3. Ask the provider for the ICD10 codes (diagnosis) and CPT codes (procedure) that will be submitted on a claim BEFORE accepting anything more than a routine medical exam.
4. Keep a copy of your insurance plan handy, and reference it BEFORE accepting any major procedure.
5. Keep every Explanation of Benefits (EOB) you receive from an insurer (those envelopes so many of us shred without opening because they advertise, “Not a bill”).
6. READ your EOBs, line-by-line, and take note of any asterisk (*) or reference code detail. Often, EOBs indicate when a provider has not submitted the claim attachment documentation needed to process a claim appropriately. If you see an error or a reference to missing/incorrect documentation, call your provider. If you see an indication that a claim will not be paid (which will have a reason or reference code attached), call your provider. Have them walk you through their remedy?—?and also have them provide you with the documentation that they submit to the insurer, along with the date and address to which the materials were sent.

As a provider:

1. UNDERSTAND THAT THIS HAPPENS. Unless you are a small, independently-operated physician group, you estimate a certain percentage of your claims will be denied each year?—?and you account for that lack of revenue in your operating budget. KNOW THAT EACH CLAIM DENIAL REPRESENTS A PATIENT DEBT THAT HAS REAL CONSEQUENCES. Keep that fact in mind each time you review your first-pass adjudication rate with your insurer.
2. Periodically (as often as possible) audit your coding and billing departments for errors. Even the most innocuous-seeming error (as the one that kicked off this series?—?using the ICD-10 code for a shoulder labrum tear when the injury was a hip labrum tear) has downstream consequences to your revenue cycle, any referral, and the patient’s medical record and pocketbook.
3. Periodically audit the efficacy of your claim appeals process, and the team performing it. If you’re not submitting the appropriate documentation to support an appeal, it will be denied, and the cycle of woe for the patients will continue.
4. When you appeal a claim and it IS denied, engage the patient. Explain the appeal process to them, provide the documentation that you gave the insurer, help the patient understand what should have been approved and why?—?and support them in whatever remedy path they decide to pursue.
5. Restating, for emphasis: KNOW THAT EACH CLAIM DENIAL REPRESENTS A PATIENT DEBT THAT HAS REAL CONSEQUENCES.

It’s shameful that we should have to be so vigilant?—?even paranoid?—?just to make sure the health insurance that so many pay good (and large) money for actually pays for the healthcare they receive. But it’s necessary.

Fingers crossed that the medical debt dragon is slain for Blondie’s family in my next update.