Likely, you’ve at least heard of the BCBS-Thomas/Love Settlement.
Likely, you’ve at least heard of the BCBS-Thomas/Love Settlement. It’s a complicated affair, but the end result is that the settlement possibly installed a few teeth into your payer negotiation arsenal, such as more transparency in fee schedules, stricter adherence to true medical necessity standards, and more reasonable deadlines for credentialing reviews.
The settlement also required some of the Blues to set up a “Level II Post-Service Provider Appeal” for medical necessity and billing disputes. External review is voluntary and binding for both parties. The purpose is to allow you the opportunity for independent review of the application of coding and payment rules and methodologies by the plans. Sounds like good news, but here are few details you should know:
Before submitting a Level II appeal, make sure you understand the reason behind the Level I denial. Was it based on an allowed plan policy change? Don’t pay for the “privilege” of a second-level review only to receive a ruling that the first-level denial is being upheld on the grounds that it is consistent with a plan’s published policies. Not receiving payment for claims is bad enough; adding appeal fees on top of that to uphold the denial is a double insult.
The cost of review is not published, so inquire first before beginning the process so you’re not surprised by unexpected costs. Example: A $30,000 claim may result in a fee as high as $1,500 if the cost to review is $3,000.
Granted, this appeals process is a step toward more equitable treatment of physicians, but I’m concerned that it’s not a fully functional solution. Consider these two red flags:
Frankly, this issue causes me great concern; I am not convinced this appeals process will actually help physicians. To be truly helpful, there needs to be a mechanism through which you can dispute the validity of policies, rather than simply appeal claim and medical necessity denials based on those policy changes.
is founder and CEO of The Verden Group, a consulting firm that helps physicians handle the complexity and volume of change in managed care today. She writes and speaks frequently on all aspects of managed care. She can be reached at firstname.lastname@example.org or by visiting www.theverdengroup.com.