Prior authorization: how I got $4000 back from denied claims

One of my friends in our google group recently read my post “How I took an insurance company to court and won.” He had a similar complaint about WellCare Medicare advantage. Here’s what he had to say:

I have a total of $4000 in unpaid claims from Wellcare, mostly for 66984. They required prior authorization (PA), which we obtained and attached to claims. They denied claims stating no prior auth. Yes, they denied claims stating the PA number THEY gave us was incorrect. When we call they said they wouldn’t reprocess the claims, stating we had to appeal (even though it was their own processing error). We filed appeal per their instructions, stating clearly the issue, and they came back every time still denying payment and stating the determination is final (ie, no further recourse). We are contracted with Wellcare via our PO, and asked them for assistance, but were only told that their own point of contact from Wellcare doesn’t respond to their repeated attempts to contact them. Other practices are impacted by similar issues. Oddly, all the 66984 denials were only for one of the two eyes for the patient…ie, they paid one eye, and not the other, despite us following the exact same process for both.

After reading your success story, I’m motivated to bring legal action. Can you specify what you did to bring your concern to a hearing? In my state we can file small claims up to $6500, which I’d like to do in order to eliminate legal fees.

In the meantime, I’ve stopped doing any surgery on Wellcare patients, and stopped seeing any new Wellcare patients. My 1099 was about $14k from them last year. I do hate to lose that, but sometimes its just not worth the headache and hassle. The patients end up suffering, which is the saddest part.

Here’s how I responded: For your WellCare schenanigans, the statute of limitations for violation of contract depends on state but is usually 4-6 years. Many states have laws that if someone violates the contract they pay the opposing party’s attorney fees if they lose (fee shifting statute) but for $4000 I doubt any attorney would be interested. And yes, I have a plaintiff’s class action attorney who is part of a well known nationwide firm. But contractually you might have to go to arbitration rather than filing a case.

If WellCare is stiffing you, assuming that it’s a Medicare advantage program, I would complain to your federal congressman. This is assuming you’ve made every effort to resolve it with them and have copies of letters denying appeals, documentation of phone calls etc.

For my practice address, a quick google search gets you to the contact page: I would pick “help with a federal agency” and if you have time and it’s a large amount I would request a personal meeting. I would state that Medicare advantage programs are regulated by and under the jurisdiction of CMS, and that MA programs are required to provide the same benefits that original Medicare covers. I would tell them that 66984 and 66984-79 is a covered service under original Medicare and that WellCare didn’t pay despite having a auth for both surgeries and ask them to investigate.

As some of you already know, during covid last year I asked my congressman to investigate why Noridian (traditional Medicare) didn’t pay me for Medicare secondary to commercial for about 10 claims. A few months later I got a EOB for about $800 for all these claims!

So here’s a cut and paste of part of my friend’s letter:

While this in itself is a barrier to care, we have followed their rules and obtained PA prior to performing surgical services for all Wellcare beneficiaries. However, for six different patients, Wellcare has denied payment for these pre-approved surgeries.
To be more specific, we have in each case obtained a PA number from Wellcare prior to cataract surgery. We then attach this number to our claim for payment as we do with all claims that require PA. However, in six patients, Wellcare has denied payment for these claims, stating “Prior Authorization Absent”. Obviously, this is a technical glitch on their part, and we have in each case called Wellcare to dispute the denial. They, in each case, acknowledge it is an error on their part, but have asked us to submit an appeal to remedy the situation and get paid. We have followed this procedure in each situation, and STILL had the claims denied and been given a “Final Notice of Determination”, meaning that all our options for payment have been exhausted. We have worked with our physician organization (PO), XXXX, who does our contracting with Wellcare, but they themselves have encountered unreturned phone calls and emails from Wellcare regarding this matter.
As you know, Medicare Advantage plans such as Wellcare are regulated by and under the jurisdiction of CMS, and are required to provide the same benefits as original Medicare. We are seeking investigation of Wellcare for abuse, given that they are not paying for services (CPT codes 66984 and 66982) which are covered under original Medicare. In addition, Wellcare does not provide sufficient provider services, as we have no direct contact with Wellcare to resolve matters such as this. We obviously are also seeking payment for unpaid claims, which do total around $4000. We will never recoup the number of lost hours spent chasing our tails, but we hope that CMS can pressure Wellcare to fix their process, or else not be eligible to provide Medicare Advantage products.
I have attached an example of the prior authorization and surgery denial for the same patient. I can provide a complete record of the abuse to CMS upon request.

It took just an hour for his Congressman’s office to respond that they filed an inquiry with CMS. Here’s what happened: In about 1 week I received a detailed response from CMS, which basically said that Wellcare denied any wrongdoing. Not really surprising considering their bad behavior leading up to this. The good news is that we have documentation that contradicts their side of the story, and will be corresponding directly to CMS with all appropriate documentation. However, interestingly enough, today I just received full payment for the example case we sent to CMS. Coincidence? I think not. I will echo what Howie and others have said. If you take the time to get to know your reps, and go through the appropriate channels to hold insurance companies accountable for their bullshit, you CAN be successful.

Three weeks later, my friend got paid for the rest of the claims:

Final followup on this Wellcare issue. As mentioned, just two weeks after “poking” Wellcare via a CMS inquiry initiated by my U.S. Rep office, we miraculously received payment from Wellcare on two of the claims. They denied wrongdoing of course. After not getting payment for four claims that were still outstanding, I reached back out to my Rep’s office and asked them to file a followup inquiry with CMS. They did…and wait for it, all remaining claims paid less than a week later.

Lessons: 1. Meet your local reps. They can be great resources when it comes to investigating medicare advantage plans gone bad. 2. Be persistent. Don’t just write off unpaid insurance claims when you know you are right. If insurance companies think we are pushovers, we will continue to be treated as pushovers. 3. Do your own billing. No way a billing company takes these steps. Have a great and safe July 4th everyone..I’ll be enjoying it with an extra $4000 in my pocket!

So if you have any Medicare advantage claims denied for prior authorization, contact your federal legislator’s office. Even better, let’s be proactive. Many medical societies including the AAO are trying to get a federal law, HR 3173, also known as the Seniors Timely Access to Care act, passed. It’s a bipartisan bill aimed to increase transparency and streamline the prior authorization process.

Input from ophthalmologists is especially important given Aetna’s recent decision to require prior authorization for ALL cataract surgeries since July 2021, but even if you aren’t an ophthalmologist, click on this link to write your legislators to let them know you support this rule:

I’ve read articles on physician social media about how a lot of physician run practices are getting screwed with prior authorization. Don’t be a chronic complainer. We can whine to each other until our faces are blue, but influencing the decision makers is what will effect change and make our lives easier. If all 435 house reps heard three stories from docs in their district like the one above, I have no doubt HR 3173 would pass in 15 seconds.

If you’re a practice owner, this is one of the best moves you can make to reduce your overhead and frustrations by not having to hire more staff to deal with this. I’ve said it before and will say it again: meeting your Congressmen is one of the best moves you can make.

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