By: Karina Gonzalez
As many know, out-of-network providers have much different appeal rights with commercial plans than in-network providers. It is important to understand each health plan’s appeal procedure as well as time requirements for an appeal may vary. However, the appeal process is still one of the most important tools providers have to get paid in the current environment of reduced reimbursements, caps on the number and frequency of services, bundled payments based on specific codes, delayed payments, daily errors in claims processing leading to denied claims, claw backs, and the list goes on.
There is no right to an external appeal process for out-of-network providers. In Florida, AHCA has a voluntary independent dispute resolution program, MAXIMUS, to assist providers and managed care health plans in resolving claims disputes for underpaid or overpaid claims. While this program can be a source for resolution, it has its own set of eligibility requirements. Also, the entity that loses has to pay the review costs and if the case is fairly complex these costs may add up. MAXIMUS submits its findings to AHCA and the decision is final.
Out-of-network providers receive only one level of appeal from commercial health plans, and need to make it count. Many times, on a denied claim or a disputed claim, the provider will send in medical records for reconsideration of the denial. When a plan receives medical records, reviews them, and upholds its initial denial, a provider is considered to have exhausted its right of appeal and the only remaining avenue is to then file a lawsuit. If medical records are sent in with a letter stating that the denied claim is being appealed, then a provider has exhausted its one appeal. On the other hand, if the records are sent in without referencing it as an appeal then many health plans will not treat the review as an appeal. Thereby the provider has protected its one chance to argue strenuously and provide supporting documentation and information in addition to the medical records.