Physician advocates intervene to get insurers to pay up

The Medical Society of Virginia's program is one of many that help resolve claims problems.

By Julie A. Jacob, AMNews staff. June 17, 2002.

When Trigon Healthcare announced it wasn't going to recognize a certain coding extender, the Medical Society of Virginia's physician practice advocate called company officials and reminded them that state law requires the insurer to recognize it.

Trigon changed its policy.

That's just one of the many claims-related problems the advocate has solved in the three years the society's program has been in place.

"We're finding that we are able to resolve a lot of things," said physician practice advocate Rose Moore, who has more than 20 years of billing and coding experience. "[Insurers] think doctors' offices are too busy to do these appeals. ... When we let the insurers know we are involved in this, a lot of times they back down."

Services, which are free to society members, include review of denied, delayed or retroactively denied claims; a hassle factor log to report claims payment problems; telephone calls and letters placed to insurers on behalf of physicians; and a telephone coding hot line.

Moore and her assistant also meet regularly with medical directors from the state's major managed care companies -- Trigon, Cigna Healthcare, UnitedHealthcare and Aetna -- to discuss physicians' concerns regarding claims payment issues.

Retroactive denials of claims is a big problem, she said, despite a Virginia law limiting such denials to 12 months after the claim is paid.

A reminder of the state law often is enough to get insurers to rescind the retroactive claims denial.

"We make them abide by the state code of Virginia. We throw that at them all the time," said Moore. [...]