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Payer Policy Disagreements

3rd Party Billing and Collections
in 3rd Party Billing and Collections

Payer Policy Disagreements: What’s a Provider to Do?

By: KMC University & Nicki Brooks, CPPM

Are you Stuck in Payer Policy Disagreements?

We have all been there… the latest Payer Newsletter comes out with a new policy regarding coverage or reimbursement that you disagree with. It’s frustrating… and oh so hard not to react negatively. That feeling of hopelessness comes over you, and you want to lash out. What can be done?

We have worked closely with State Associations, as well as the American Chiropractic Association (ACA), and found that advocacy works best. Most often the strongest voices are those of the contracted providers, and, even more so, the patients. So, speak up and let your voice be heard!

Recently, United HealthCare changed their manipulation policy to exclude treatment of headaches, even though their headache policy includes treatment for cervicogenic headaches. Companies like ours, associations like the ACA, state associations, Clinical Compass, and the Chiropractic Congress all leaped into action to call attention to this ridiculous policy.

Wondering what the best and most effective way to dispute a policy is? Below is a simplified list of step-by-step actions to take when disputing policy:

Find the payer’s language. This is accomplished by locating the medical review policy on the payer’s website.

  • Learn it.
  • Locate it. (page number)
  • Copy it.

Compare policies (old vs new).

Keep a copy (electronic or paper print-out) of all reimbursement policies related to services you provide. That may include looking at both chiropractic or manipulative policies as well as physical therapy policies for those service codes.

Locate similar policies from other major payers. Do other payers similarly disallow or limit services? Or do they cover them?

  • Include language from these similar policies in your communication to the payer’s Medical Director.
  • Keep it simple. ASK:
    • Why has their research led to the exclusion of services or conditions that other payers have opted to cover?
    • What is their rationale?

Draw attention to any inconsistencies.

  • Ask (respectfully) for an explanation.
    • Remember that many times medical policies are drafted or reviewed by individuals who are not familiar with physical therapy or chiropractic services.
  • Keep your eyes on the goal!
    • To resolve inconsistencies and persuade the payer to align its policies with accepted guidelines.

Review any studies referenced in the policy. Often the outcomes will support your case.

Determine who is responsible for the development of policy language.

Find common ground:

  • Use descriptive language from the Payer’s own mission statement.
  • Use some of the Medical Director’s direct quotes in your communication efforts.

Utilize your association:

  • Make them aware of your intent as a contracted provider to pursue the matter.
  • Copy them in your communication.

Finally, remember that all communication sent via email or through the postal service should be professional and succinct, yet courteous. If you follow these steps, you should be well on your way to resolving any policy disputes that have the potential to negatively impact your practice.

United HealthCare overturned their policy within a month due to the action taken. It can be done. We just need to work together.