Should I bother? (long)

[akashafive]

Hello, I need some advice regarding appealing an insurance claim denial.

Basically, I've provided several sessions as a provider for MVP's TriVantage plan which covers massage therapy, beginning back in March of 2008, and going through October 2008. I've been denied and need to provide a "brief, clear explanation" supporting why I should be paid (the claims only total $90). This is causing me a lot of frustration as I have no idea how to provide the requested info briefly when it involves so much!

(Background)
The person who contacted me about signing on to the program, stated that I'd be provided with training on the procedures and paperwork involved. Needless to say all I got was an email with a CMS1500 form, a form for the client to sign saying they'd pay if the insurance wouldn't, and another paper stating which plans covered mt and how much the clients co-pay would be (50%).

Beginning in March with the first client, I began filling out the claim forms and mailing them in (to who I now know was a third party), only to be denied because of missing or invalid information. I continued to correct my mistakes and resubmit, eventually I received a payment, but for the wrong amount because once again I had made a mistake on the form. And yes, I had been getting help from other LMT's where I worked who had a lot of experience filing claims, but as those were for no-fault, and mine weren't, I guess there were several differences.

The denial letters I received had a payee ID that allowed me to register on MVP's providers website, and recognized me as such in their system, this led me to believe I could submit my claims online and save a lot of time and paperwork. I did just that, and when I checked up on the status, I was thrilled to see payment had been issued for the correct amount in October 2008 (it never said to whom it had been issued, though).

In December, I still had not received the check. After calling MVP, it turned out I could only to submit to the third party via mail, who then submitted to MVP, who issues the payment to the third party, who then pays me. Since I submitted to MVP directly, the third party had no paperwork to connect with the payment MVP sent them after processing my claims. The third party told me to resubmit the claims via fax. By this time it was the beginning of January 2009. Shortly there after, I received a fax of the denial letters stating the time limit for filing had expired (90 days from date of service). At no time during this whole fiasco of submitting, being denied, and resubmitting, had I ever been told I was beyond the filing time period.

To make matters more complicated, I've actually left my practice and have moved out of state. I have been relying on the office manager at the center I worked at to be a go between.

I feel like giving up.

Thanks to anyone who has read all this, and I'd appreciate any words of advice or thoughts you might have.

-Lauren

[mtnlionz]

Wow, Lauren, this all sounds so complicated. I can see where you would feel like giving up. I probably would give up myself, if investing any more of my time and energy would outweigh the monetary reward of the payment.
Are you saying the amount due to you currently is $90? For that, I would let it go and chalk it up to experience, maybe write it off as a bad debt or something on your taxes and be done with it. Sounds like if the payment was made, but not made to YOU, then you don't have the option of billing the client.
I would explore this company via the Better Business Bureau to see if there have been any claims about poor business practices. That could likely get you absolutely nowhere, but filing your own story might be helpful to someone down the line if indeed something is fishy. The process of having to file via a third party seems very suspicious to me, but I haven't dealt with insurance in many years and have no patience for the process. It's not been worth it in my practice.
I'm interested to hear others' ideas.
Good luck.

[mtnlionz]

Quote:
The process of having to file via a third party seems very suspicious to me, but I haven't dealt with insurance in many years and have no patience for the process.


This is common with CAM coverage on health plans. Most health plans, be they BC/BS, Cigna, Aetna, etc., will use third party companies to adminster their CAM benefits. It's known in the industry as a "carve-out." The insurance companies are basically contracting with a third-party for use of their established provider network rather than having to develop and maintain their own.

Ah. Good to know. Thanks for clarifying.

[akashafive]

Thank you for the replies so far.

Pete, thanks for the info and you are correct, the issue was largely due to my unfamiliarity with insurance billing. Third-party billing was never a topic in school, just how to fill out the forms for medical claims. And the info, like 90 day filing period, was included, but as they just kept sending me denials that made no reference to that as a denial reason, I just assumed as long as you submitted the original claim within that time period they would let you continue to make corrections.

And even though as I'm unemployed at the moment and every little bit would help, I like your suggestion, mtnlionz, of writing it off as a bad debt. I hadn't thought of that possibility before.

Definitely a learning experience for me. Thanks again!

-Lauren*^_^*

[Rose of Sharon]

The person who contacted me about signing on to the program, stated that I'd be provided with training on the procedures and paperwork involved. Needless to say all I got was an email with a CMS1500 form, a form for the client to sign saying they'd pay if the insurance wouldn't, and another paper stating which plans covered mt and how much the clients co-pay would be (50%).





-Lauren

I would just bill the client and send along the denial letter.