Practice Management Alert

If an insurer is not responding to claim appeals within the contracted 30 days, and numerous appeals are pending or a payer is bundling procedures into a global fee, you should consider filing a complaint with your state insurance commissioner (IC).
 
"Your state insurance commissioner is the next-to-last step in attempting to resolve an issue between the provider and carrier," says Steven M. Verno, NREMTP, CMBSI, director of reimbursement for Emergency Medicine Specialists, a 23-physician practice in Hollywood, Fla., and compliance director for the Medical Association of Billers, based in Las Vegas. The last step would be taking the carrier through the litigation process for breach of contract.
 
In most states, the IC enforces state regulations and laws governing the licensing and operation of insurance companies, including healthcare. Among the carrier problems practices face that Verno says could be brought to the attention of the IC include:

  failure to comply with your state's prompt-payment law
  failure to abide by the terms of the contract between the provider and carrier
  failure to pay your claims
  downcoding claims
  carrier refund requests beyond the timeframe allowed by law
  a violation of the Coordination of Benefits rules
  failure to respond to an appeal.
Before Filing Complaint, Give Payer a Chance
Before you file a complaint with the IC, make every reasonable attempt to resolve the issue with the carrier, Verno recommends. "Send a letter of appeal, by certified mail, return receipt requested and allow the carrier an established time to respond. Attach all necessary documents to support your case. If the carrier denies your appeal or refuses to respond, file a complaint with the IC," he says.
Items to Include
To file a complaint with the commissioner, write a letter explaining the problem, what occurred, and the remedy you seek and your rationale for it. Allow up to 60 days for the IC's office to respond, he adds. Verno recommends enclosing a copy of the following when you complain: the original claim  the explanation of benefits (EOB) form showing the reason why you appealed  your appeal letter  supporting documents, such as statutes, case law, and documents from any regulating agency  the certified mail/return receipt used to mail your appeal to the carrier  the carrier's response, if any  a copy of a spreadsheet showing the carrier's unpaid account summary.
States Differ in Handling Provider Complaints
 
 
ICs in some states, such as Florida, do not involve themselves with issues between carriers and providers, Verno says. Other state commissioners, however, will respond to provider complaints. Verno points to Texas, New York and Louisiana as examples of states in which the IC's office has helped him resolve problems with insurers.