UD Live with Leslie Lobel: Insurance Claims, Authorizations, and Denials...Oh, My!

Leslie Lobel, Undivided's Head of Health Plan Advocacy Services, explains how to handle in-network and out-of-network claims, authorizations, and denials during this Undivided Live event.

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Video Transcript

Thank you all for joining us. Welcome to Undivided Live. Today we're going to be talking about many people's least favorite subject, although I know one person in this is going to say something different. They love this subject, and that is insurance. Dealing with insurance companies can be one of the most frustrating experiences for many of our families, even for... even for the fan of insurance. Unfortunately, it's not something that we can ignore. Our lives quite literally depend on it. I'm Jason Lehmbeck, CEO of Undivided and dad to three boys, where we are in the middle of at least two fun insurance projects for my oldest son Noah, relating to his AAC device and his walker, and so I am excited to be here to talk about this conversation, but I'm also joined here by Lindsay, who heads up our Content and Community teams at Undivided. Hi, Lindsay. -- Hey, everybody. And our very own Leslie Lobel, our head of Health Plan Advocacy Services. Hello, Leslie. Hey, guys. I'm raring to go. Ready to rock. You love insurance. It's true. Yeah, I love the positive outcomes. I love the positive. You like working the insurance. Let's talk to the only person that either of us know who actually likes to talk to health plan representatives, but more importantly, she speaks their language. So, Leslie, as Jason said, insurance is... it's emotional. It's the gatekeeper for our health, and like Jason just said, our lives, whether that be literal life or quality of life, and insurance companies, they can really... they can... you can correct me, but it feels like they can deny anything they want really, but instead of staying frustrated, we want people to become empowered. So I want to start with out-of-network claims. So how can we not make it easier for insurance... insurance companies to deny? What can parents do? Well, first of all, thank you for the opportunity to actually talk about insurance, because I dig it. I started by figuring it out for my child, and now I like to help other families figure it out for themselves and for their kids. So there's a simple and a... and a longer answer your question. The simple question is to know the most common reason that claims are denied and try like heck to avoid those. It can be stuff that’s simple, like making sure that you're filing a complete and correct claim, and I think we're going to be sharing some documentation about that during this event. You want to make sure that the provider's information is complete. There's a lot of fields there that we'll be digging into in our guide. And also, here's one. You want to make sure that the child's name is complete. I just had a case where we were submitting claims for Max, and the plan was denying them. Why? Because Max's name is actually Maximilian. That's actually what happened. So make sure your provider’s information is complete and your child's information is complete, and you're using their full name. Also, make sure you're filing the claims on time. The plans have timely filing limits. It's real short for Cigna, only six months. For Blue Cross/Blue Shield, United and Aetna, it's more like a year or 18 months. The common reasons your claims are denied can be more complex than those simple ones. It could be a coding issue. The plans love adding modifiers and changing codes on their billing... acceptable billing codes. A specific diagnosis can be excluded. Speech can be covered, but not for articulation. And it can be that a pre authorization was needed and it wasn't requested. So those are the simple reasons that a claim can be denied. The longer answer is that you really do need to understand your coverage and your benefit. That thing that people don't want to know anything about, you really do want to know it. A: you need to know that that pre authorization is required, and for out-of- network claims, you're the one who's responsible for it. You want to know about your out-of-network deductible. How many claims in here are going to process the deductible instead of processing to you, and what's the share of cost that the plan will pay once they start paying? So that's kind of why claims get denied in network, sort of an overview. And do you... thinking about.... I know I get coaching encouragement to look at these plans and understand the details and any tips and tricks on what... Is it as simple as print this thing out and really read it before bed and try not to fall asleep, or you talked about a couple key things to look for, like how do you make it through the slog of those insurance benefits and...? Well, for the claims, it's a matter of filling out a checklist. For speaking the language of the plan, it really is a few key phrases so that you understand what they mean, so when the plan says them, your conversation doesn't end because you have to get off the phone and look up what that means. If you can have the vocabulary and the lingo already loaded, either in a cheat sheet or hopefully, if I've done my job right, baked into your brain, then you can further the cause by understanding the lingo that's being thrown at you. And as Lindsay mentioned, Donna shared in the chat window the one-on- one document, so I think there's some really good helpful tips there and some of the key lingo. It's the nuts and bolts are in there. Check this box. Fill in this field. Avoid those easy denials to avoid. And so what if parents are in-network and they're going through their in-network coverage. Is it all easy street and nothing to worry about? Well, that's a really good question and the answer is that it's not really easy street, but I'd say that it's easier street, right? You don't have to submit your own claims and pass the much lower network deductible. You're going to only do your copay, but the in-network buyer still has to be well, right? What do you have to do? You have to compare your EOB to your billing statement, especially if you're working with a large medical group or a hospital based plan. I'm not talking here about your friendly neighborhood OT, PT, or speech provider, but you really... and Jason, you know this. You really need to dig into that EOB and make sure you're not being charged for something that the provider's not entitled to, or you're not being charged for something that you've already paid. And here in-network, interesting thing is that the plan can almost be more of an ally than an adversary. If you read that EOB, it tells you what the network contract holds the provider liable to. If you've overpaid a claim to your large hospital group or in-network specialists, they're not going to call you and say, “We've got your 75 bucks. Do you want it back?” Right? You can find that money hidden in comparing the EOB for the in-network claim. And I mean, I don't know about you guys, but I like to decide how I spend my money. You may want to leave that money on account with the billing office of the network provider, but you may not be going back there for a year or two, in which case you can call them up and get your money back. My husband and I actually like to use that money to go out to fancy lunches together, so that's kind of a motivation to read that EOB, whether it's in or out-of-network. I have to say, Leslie, that has happened to me more times than I would care to admit. And then you're like, so you got this check. I mean, I call and it's unbelievable. You got this check, you know this is... nobody called? It's like, “No, we’ll send the check, it's in the mail.” No apology. No... I mean, I just... like, great, money, check, not checking where this is supposed to go. We're just going to cash it. Those are some of my favorite checks. We go to the best restaurants in Santa Monica, if we don't have other bills to pay. We try to get those checks to something with an ocean view. So what do you have for me next? Yeah, I think the thing is, and you've described some helpful tips and how to really kind of stay on top of this, but even if you’re staying on top of it, you do everything right, insurance companies still can deny, right? And I know, Lindsay, this has happened to you. Leslie, this has happened to you, it's happened to me. I'm sure everybody listening in can probably at least have... channel one experience where they did everything right and you still got the denial. When they do, we can receive one paragraph that says, “You've been denied,” or seven pages. If we have a valid appeal and decide to file, what do we do with that letter? What's next? Okay, that's a multi-part question. The first thing you need to do before you consider an appeal is to understand the denial. The denial is the basis for the appeal. The first thing you want to do is deconstruct the no in the denial letter. Take a deep breath. Read the letter. Reread the letter. You might have to read it several times to really find the reason that they're saying no. Once you find that reason, you want to address that specific no. You want to make sure that you're preparing to mount the argument about the same issue that the plan is denying on. Don't fight a different fight than the one that's queued up in that letter. And then you want to hone in on the why of that denial. Are they allowed to say no? And the way that you figure that out is to go to the health plan’s evidence of coverage, which is like a 110 page long document that you can get from customer service, download yourself, or in some cases, get from human resources. The good news about that 110 page document is it always has a great table of contents, and you can find right in there speech therapy provisions, requirements, and exclusions. We've gone there together. Right, Lindsay? I'm having flashbacks. Right. And in there, they commit to what they are and aren't going to do, and if you can find a reason in there that you can hold them to, then you're ready. You're ready for an appeal. It's going to tell you right there what hoop you have to jump through, and then you enlist help and create documentation to jump through that specific hoop that they're holding up for you. And then once again, you go back to that letter because that letter is going to give you the chain of command, where you're going to submit, what you're going to submit, how you're able to submit it, and it's going to tell you first, second, and third levels of appeal. So the answer is figure out if you have an answer to this denial and then appeal away. And do you feel like... I don't like that face you made, Lindsay. I was channeling my experience... Go ahead, Jason, I’ll talk about... No, you go ahead. Well, I just... It is so stressful, and really I... Leslie and I... Leslie helped me through a really horrible and... exactly how Jason led into this question. The whole chain of denials we were getting would come from seven to ten pages of everything you could think of, the whole kitchen sink, and then the next denial would be like one sentence that would give you absolutely nothing to pick apart, but the way that you just laid it out, Leslie, I know it sounds like a lot, and it is a lot, right? And I know we'll talk about that. Sometimes you need somebody like Leslie -- I did -- to help me break it down, but it completely changed the way I look at those letters, and really, we can't even understate the importance of the first thing you said about understand, deconstruct the no, because I remember when we were first talking, you're like, “Lindsay, you're fighting a battle that isn't on the paper. I hear what you're saying, but that isn't even why they're denying.” Right. Yeah. This is essential steps. This is not just chitter chat. It really is what you need to do. A lot of times you'll be so... And I'm guilty of getting baked in on something. You got to make sure that you're arguing what they’re arguing, and then you can turn it around against them or back off and know that this is not one that's likely to progress. That's important too. Not every denial leads to an appeal, and my goal for myself, and for my clients, and for Undivided’s clients is that we make sure we're putting our time and energy into the right fight, and that if it is the right fight that we gather all the people on our team to support that argument and write a killer cover letter that says what you want to have done, what outcome you want, so... And that's... when you say team, you're talking about your pediatrician, your orthopedist, depending on the particular situation, you want those players at the table helping you make the best case possible. Right. You want the treating therapist or provider, and then you want a bigger picture doctor, because the therapist can say, “Here's the progress that's being made,” but they can't really say, “My services are medically necessary. My services are essential.” That's where your letter of medical necessity comes in, and then it's all capped off with that killer cover letter, which if you do it right, is successful and I dare say cathartic, right? You can... Yeah, you can dig into speaking through that letter to the person at the plan who's reading that letter. That's a great strategy. When I'm writing those letters, I imagine the person who's reading them and I try to be concise and respectful while still confrontational. It's a balance, right? You want to speak to them and lay out a compelling argument that's related to what they are required to do, not what you want them to do, but what they're actually required to do. That's the essence of the denial to appeal. I think that's perfect. What are they required to do? Why did they say no? And then all of your team coming together to support what... not only what your child needs, but what they're saying is required, right? So all those... those are the three main pieces. Yep. -- Right. Got it. -- And it all goes... It all goes fast from there, right? It's like a two day turnaround from the insurance company? Well, no but there is a knowable period of time and it's usually in that letter or knowable by the plan. The thing that I like to impart to people is those letters... Yeah, there's a couple of pages that you can put right into the circular file or the shredder, but I like to remind people that the information isn't in there because the plan wants to put it there. The plan puts it there because it's required for the plan to put it there, and some of that information is to your benefit, and that's usually the information that they bury the deepest, so you really have to stop and take a breath and decompress and read that letter. Sometimes all I need to do with the family is help them read that letter, to take the emotion out of it and read what's in there, and they'll say, “Oh yeah, I can do that.” It's just a matter of, yeah, I've had that experience. People call me and we read the letter through together and they say, “Okay, cool, I can do that,” or, “I need help to do that, but now I understand what's going on.” Yeah. Use that letter, use that EOB, use everything they send you to your best advantage. They're sending it to you because they have to, not because they want to. It also feels a bit like all of the systems that our families deal in, in that... Okay, I will speak from my personal experience with these denials, but that they're just waiting to see who says no, and I know we've talked about this in the past, Leslie, but I would love for you to share what are the statistics of how many insurance companies deny and how many parents fight back, just so we can really kind of put into perspective. They're counting on you... They're counting on you not to do it. That’s how it feels. They're trying to weed out the people who are going to say, “Oh, no? Oh, okay.” Before I go into those statistics, I just thought of something that I want to add, which is the first no is not the last no. You have to be will... if you have a winner argument or a likely winner argument, you've got to be willing to wade through all those levels of no. There may be a golden egg in there somewhere for you, but I have two statistics that I think really sort of address the range of your question. The first one was in... was posted up on Facebook. Thank you for posting it and sharing it because it's a really compelling reason... Sorry, really compelling statistic. One out of every seven claims gets denied on the first go around. I know it sometimes feels like families have all seven of those claims in one envelope, but one out of seven get denied on the first processing. That's about 2 million a year. So we want, especially with those early answers to how to avoid the easy no, we want to pull our claims out of that 200 million. The second factoid that I want to share is that... this is from the Kaiser Family Foundation, which is a great organization. I get their newsletter. Maybe you do, maybe you don't. Their statistic in 2017 that of those 200 million denied claims only 0.5%, half of 1% of denied claims are appealed. Wow. -- That's crazy. And of the ones that get appealed, of the ones that go to the Department of Managed Health Care, just around 50% of those denials get overturned. So that's my message to all of us, and also to remind to myself, is we want to boost that... We want to decrease that first statistic and boost the second one, right? We want to boost that 0.5%, half of 1% of denied claims. We want to boost that number, and we really want to boost that number of denials that are overturned. Yeah. It's like you're saying, Lindsay, it seems like a strategy. We all have thought that it's a strategy for them to do that, and the numbers bear it out. It’s working for them. We got to come back, come at them with this framework you're laying out, Leslie, on how to approach it, and really try to overcome all those depressing numbers. And to open those envelopes. Right? I like to talk about how they... sometimes I get EOBs from people and they have coffee cup stains, wine glass stains, sometimes something's chewed off of the corner. Sound familiar? Yeah. It... and I say it with affection because when it comes to my claims, I'll sometimes put them aside, right? It's tough to see them in your mailbox or your inbox. This is... I just wanted to kind of... It's a little bit of a broad question, but I guess thinking about what's happened to me, just what happens if parents continue getting denied for viable services, right? They're continuing to get a denial on the same thing every time. Maybe they win an appeal and it continues happening. Does that change the process at all or you're just starting all over again with the same denial and appeal process? Well, yes and no. Yes. You have to go back to the well if they're coming back at you, But a precedent is a really important thing. It's important in your denial letter, and if you wind up at the Department of Insurance or you wind up at the Department of Managed Health Care, or you wind up at a third party external review organization, or with a board of directors, the subcommittee at a self-insured plan, a pattern of denials, a pattern of sending you through the wringer, that's helpful. So, I try to remind myself and others that that frustration of getting that no, of that one sentence denial, you can turn that around to your advantage and point out to the plan that it's unfair treatment. It's an onerous burden on a family with a child with significant support needs, that this is how they're treating the person who is their client. So, maybe that answers your question, but yeah, you have to rework things and rework things, but a pattern of neglect, a pattern of mistreatment is compelling, especially to the watchdog organizations like the Department of Managed Health Care. That's what they're looking for, right? I've had cases where we've gotten to the attorneys at the Department of Managed Health Care and the Department of Insurance, and they actually fine. They keep track of how many times Blue Shield has denied, how many times they denied the same thing, and they fine the plans. Not fines that get paid to the family, which I wish they did, but they're attempting to hold the plan accountable in the larger sense while we're attempting to hold the plan accountable for doing the same thing over and over on the micro level. -- That makes sense. We have a question from the families that are listening in, from Beth. She says it seems like there's been an increase in superbills being denied lately. Is that something you're seeing in your practice? Well, we have a steady flow of denials, but what I do see towards the end of the plan year, which is just my own surmising, I don't have hard data for it, -- but I never let a lack of hard data dissuade me from forming a conclusion -- is that once people are meeting that out-of-network deductible and it's actually time for the plan to pay, suddenly allowed amounts go down. Suddenly... so it may be tied to the time of year. They are quick to process the ones they don't have to pay. The ones that go... because we see it, right? Because we manage a lot of claims for people. January, February, March, when most people are in their deductible, those claims process a lot faster than 30 days. The ones where they're paying, they're either denying or they're getting held up in one way or another. So, that... hopefully that answers your question. It does. We need new levels of emoticons for angry and pissed off. I mean, you can just see the happy approvers in February and March. Yeah, this is all approved, and then the meain people show up. Right? -- Well. it's amazing though. It's like, okay, so all these... again, from my experience, it's like this has been approved until June and then miraculously, this medically necessary therapy or procedure that's been fine all year, now that we've met our out-of-pocket, max, right, now all of a sudden, it's not necessary. I mean, somehow it magically happens when you reach your limits. It's really... It's not set up in your favor, that's for sure, but our job, collectively and individually, is to push them where they can, and to hold their feet to the fire where we can, and to pick and choose which battles are worth that endless live chat or the time on hold. The more you know before you pick up the phone to get on hold, the better your time will be invested. That's why you need to know that common list of denials, so that you can read that denial reason on that claim and figure out before you call. Know enough to be able to triage the claim and not be calling to ask them to tell you why it's denied, although sometimes you have to do that, but really mine the information on that EOB and call with an agenda, call knowing why the claim is denied or with a list of reasons that seem likely. You kind of have to know at least as much as customer service. Right, right. So I want to shift to a positive insight you've shared with me over the last year or so that I didn't frankly know to really tap into, and that's... we did receive a lot of questions about Medi-Cal. I know you're not a Medi-Cal expert, but something you've spent a lot of time helping families on recently, including mine, is the... being aware of how Medi-Cal works with private insurance and when and where you might be able to take advantage of that and really get the coverage that your child has a right to. Right, it's really important to make sure that you're digging into all the coverage that you have, and the common scenario for... that's common to my family and common to many of the families that I work with is the PPO primary and the Medi-Cal secondary, right? And if you have the right kind of Medi-Cal and you have the right kind of provider, then once your primary pays, the provider can submit to Medi-Cal if they're a Medi-Cal provider and you can be absolved of your copay and deductible. The state's feeling on it is to encourage people to maintain that PPO by standing behind them as a secondary, and helping them out with the copay. They're invested in supporting you keeping that primary coverage going. So what you want to do, and it's going to be, again, with large groups, hospital based providers, the people at Children's, the people at UCLA, people at Cedars, they can be preeminent specialists but they may... so you shouldn't judge who is and who isn't a Medi-Cal provider, but what you want to do is find out who accepts Medi-Cal secondary and where that bill can come. If, God forbid, your child is in hospital or they're seeing someone in a hospital setting, that's a great question to ask. Also ABA providers. Many ABA providers accept certain kinds of Medi-Cal, and you cannot submit an out-of-network claim to Medi-Cal. You have to be working with the Medi-Cal provider. So that's going to be hospitals or hospital based providers, like I said, equipment providers, durable medical equipment providers, it's going to be some ABA providers. Those kinds of services, it’s appropriate to ask, “Do you accept Medi-Cal as secondary?” I just sent my daughter's Medi-Cal card off to aprovider who billed me $617.29. I thought, oh, you're going to take Medi-Cal secondary. It's an easy question. They'll either say yes or no. And yesterday they said yes to me. So that's a lot of lunches with ocean views. And make sure you ask because Leslie and I found this as well. There was a procedure my daughter kept getting denied for, and it almost pained me to not continue down the road because it had been several times and it should be allowed, but then we didn't even realize the provider was also a Medi-Cal provider, so the most important thing is now I still might go through that appeal process, because they should be providing this, but if they don't and we lose in the end, then I know that we don't have to pay exorbitant amounts out of pocket and she gets what she needs, but I never would have... I mean, they knew we had Medi-Cal. They never threw it out. So it's important to ask. Right, and we didn't think to ask, right? We both learned a lesson, right? Advocate and parent both. Oh, it didn't occur to us. It's really important to keep that... and it was a hospital based preeminent provider, right? So yeah, the admin person said, “Don't you have Medi-Cal?” “Oh, yeah.” So I learned one on that one with you. I also wanted to just point out that we are getting a little short on time, so please get any questions that you have into the chat so Leslie can answer them, but we do have a just a couple more questions. Leslie, what... Here we are. It's... I knew what day it was at the beginning. What month? It's October until the end of the year, right? But what is... what's the most important thing for parents to consider about insurance at this time of year? At this time of year, you really want to be tidying up the year, getting your claims in before you can no longer submit them, and also thinking about how you've used your insurance, how you've used your coverage, do you... if your calendar year rolls over at the end of... If your plan... your... excuse me. If your plan year rolls over at the end of the calendar year and you're starting a new plan year in January, how have you used your coverage? Have you used it enough to meet the premium? Do you want to reduce your premium and increase your copays and your deductible, which, of course, will require you to know what those terms refer to, but really to just sit and think about how you've used your plan and how you're going to use your plan in the new year, and if you have... if you still have the plan that's right for you based on your claim experience. Yeah, that makes sense. And I... you've provided, as you always do, some really helpful pointers for families listening in and with all these great tips and just thinking about everything else on our plates, sometimes it feels impossible to do this kind of work alone, especially when you think about the emotional side of it, and just the work that has to be done, and so I'd love for you to walk through just briefly, how do you help families that are... that you work with here at Undivided? Well, there is a variety of different issues that people come to me with, and I'm happy to dig in on all of them with them, but there’s... with me, there's always an essential step, and the essential step to working with people is what I've already been saying, so you know it’s integral to the process, is you need to understand your benefits and coverage before you proceed any further. You may not find it interesting, but you really have to know how your plan works. The audit... Whether you audit your own plan or whether we audit the plan for you, the audit is everything and everything starts with the audit. You need to know that information, and if you're working with us, we need to know that information too. We don't want to submit claims to you if your deductible is so high that it's never going to result in payments to you. If there's some block or stopper, we don't want to start work until we've figured out the playing field. It may not be a level playing field, but we need to figure out what the playing field is, so the first step for every family is an audit, and then past the audit, we do claims filing. We file claims, we make sure they've been received by the plan, we make sure they're processed correctly, and we keep track of everything in a nifty tidy spreadsheet. We manage those pre-auths for you if you choose, if your plan requires pre-authorization for services, and many of the services that our kids use do require pre-authorization. We can do some of that appeal work that we talked about, both in figuring out if you have a valid appeal and then handing it back to you to dig in on the gathering of the documentation and writing of the cover letter, or once we've figured out that there's some there there, we can handle the appeal for you. We can work with a durable medical equipment provider to get your order approved and to manage the endless flow of information, which has just increased this year. There's new levels of requirement, and also we can, if you determine that you need go in-network for a service, we can help you research network providers and let you know which network providers families we work with have worked with and sort of provide a questionnaire of what you might want to ask in-network providers. And also, as both of you know, people come with new projects all of the time. It's sort of like, we didn't think of that one before. So those are common projects that we work to support families on, but bring it on. We’ll tackle it. I love it. I mean I... I appreciate you taking the time today to share your insights with our families, and I know I can personally attest to... we do a weekly get together in our family where we share gratitude for the week, and Leslie ends up on the board a lot more often then maybe I would have thought when I first thought about insurance, and that's because what you do... I mean, you're this powerful partner in my... at my family's side, helping me feel like I'm taking it back to the insurance company at a base level, but a more important level, you're making sure that I'm getting all the resources my son deserves and the excellence that he deserves through those resources, and I think at the highest level, you give us the confidence we're doing all we can to support him, so I just personally, I'm just so deeply grateful for the work that you do and that your team does, and this is a... this is obviously a very emotionally fraught and technically challenging thing to be having to work on, on top of all the other things our families work on, and I'm thankful for all that you do and thankful for the knowledge you’ve shared today. Yeah, and it's hard to stop me once I get started, once I warm to my subject. Yeah, maybe I’ve said this already, but I try to say it a lot. You don't have to love what the plan is about. You just have to understand, because they understand your plan. You're going in at a disadvantage if you don't understand it as well, and I like to think that... and it's true. Reimbursement for services supports more services and more services supports better outcomes, so when I'm talking to providers and I see what they're doing for kids, I feel really gratified back at you, Jason, and back at all the families, that I'm doing a little bit to support the work that you're doing with your kids and that the people on your child’s team are doing, so it's really a big old battle partnership, so... I do have to say one thing about that. You really are... The out-of-network providers that have worked with... for me that have worked with Leslie, it's also a huge godsend to them, right? They don't take insurance. They don't want to have to deal with it, and they are very grateful to have somebody who wants to handle it, knows how to handle it, so yeah, it's been... it's been a game changer for us as well.