Insurance Committee Report

Fraudulent Investigations

⎯ Please note that Blue Cross Blue Shield is going an extra mile investigating “Fraudulent” claims by providers. They are encouraging patients to “call in” if they have any reservations about their provider’s billing.

On that note, it is important that you, as a Provider, keep an open line of communication with your patients. When you are doing expensive injections, wound care products, orthosis fitting, etc., please inform the patient the approximate amount of the bill and ask if they have any questions before it is submitted. A good percentage of fraudulent claims stem from a misunderstanding.

Claim Denials after Prior Authorization

⎯ Your best ally when a claim is denied after prior authorization is your patient. Send the patient a bill for the services that were prior authorized but denied by their insurance, and they are BEST person to contact the insurance company to find out why payment was denied. An insurance company will listen to their beneficiary more keenly, than a Provider, in order to settle the matter. Make sure your patient has all the prior authorization information.

Medicare Advantage

⎯ As our patients are migrating to Medicare Advantage Plans, it has been a real challenge extracting their original Medicare Card or number. Some of these Advantage Plan Administrators, like United Health Care, Aetna, etc, have informed the patients that they do not need to present their Medicare Card. We have found that you still need that Medicare number if you are checking deductibles or trying to pre-authorize certain treatments.

Please taken advantage of all of the training Webinars available through the APMA website and Blue Cross Blue Shield website. Many Webinars are available such as MACRA/MIPS, Coding and Billing updates, along with How to Efficiently use Availity.

All Doctors taking Medicaid Products, please verify coverage every visit through – You can enroll, your practice and verify all coverages through the State of Illinois.

Jondelle B. Jenkins, DPM

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