Having Issues With an Insurance Company? File a Complaint!

Are your insurance reimbursements taking longer to process than they should? Or do your claims always seem to be turned down for not providing information the insurer never asked for? If your practice keeps encountering these problems, you could have a strong legal case for filing a complaint against the insurer. Holistic Billing Services has walked plenty of acupuncture, massage therapy, and chiropractic practices through the complaint process over the years. Here’s a look at what we’ve learned along the way.

Your Holistic Practice and Health Insurance Complaints

Here is a tip most people billing insurance for holistic healthcare aren‘t aware of: most states have “prompt payment” legislation in place where insurers are required to resolve each provider dispute consistent with applicable law and issue a written determination usually within 45 working days after the date of receipt of the provider dispute. If you feel you have exhausted all of your options with the insurer in resolving a clean claim, take advantage of these laws by contacting your state‘s insurance commissioner to file a complaint.

How Do Prompt Payment Laws Work?

Prompt pay laws require insurance companies to either pay or deny claims from healthcare providers within a reasonable period of time. That amount of time varies by state, but is typically between 15 to 60 days. The timeframe is often shorter for electronic claims compared to old-fashioned paper claims. States attempt to compel prompt payment by imposing penalties on insurers who fail to comply with the payment deadline. 

There are some exceptions to these requirements. If the insurer needs more information or proof of additional insurance, they can receive an extension so long as they request the necessary information within the original time period. Once they receive the additional information, they are still obligated to process the insurance reimbursement in a timely manner.

Failure to comply with prompt payment requirements can carry substantial penalties, often in the form of interest payments to the provider. Insurance companies that are habitually late in their payments could also be hit by the state with hefty fines, like the $1 million fine Pennsylvania levied on UnitedHealthcare in 2019 or the $10 million fine Texas imposed on Blue Cross Blue Shield of Texas in 2020 (for prompt pay and other violations).

What Qualifies as a Clean Claim?

It’s important to remember that prompt payment laws apply specifically to clean claims. These are claims that use a standard claim form (typically claim form CMS-1500, formerly known as HCFA 1500, or claim form UB-04) or the specific electronic system used by the insurer. In both cases, the practice must be sure to complete the required fields with all the information necessary to process the claim.

“Clean” refers to both the completeness and accuracy of a submission. Insurance providers are typically quite clear about the specific information they need when providers submit a claim for processing. Documentation sometimes needs to be submitted along with certain CPT codes, so it’s important for practices to always accurately document what treatments are being administered and how time is being accounted for (especially when it comes to the new E&M billing guidelines).

When and Why to File Insurance Complaints

If an insurer is taking longer than expected to process a claim, your first step should be to check the prompt payment guidelines in your state. The Department of Insurance can provide more detailed information about the claims process and the requirements facing insurers (look up your state’s information here).

Once you’ve determined that the insurer has missed the prompt pay deadline in your state and has not requested additional information from you, the next step is to begin filing a claim. While the process can be a bit time consuming and involve some additional legwork, it’s important to hold insurance companies accountable when they fail to comply with state law. Simply giving them more time to process your claim may result in you not getting paid at all, and it may prevent you from collecting interest payments you are legally entitled to receive.

When the time comes to follow up on a claim, it’s helpful to have an experienced billing provider with a history of representing holistic practices at your side. Before you begin the complaint process, consider reaching out to a partner who already knows what steps to take in order to resolve the dispute quickly and favorably.

How to File a Complaint Against a Health Insurance Company

Step 1: Contact the Insurer

When contacting the insurer to file a complaint, be sure to remind them of your state’s prompt pay requirements and present them with detailed information about your claim (such as the date it was submitted and proof that it was delivered to them). The insurer may argue that they never received the claim, in which case you should be able to provide a copy of the original claim. Document all correspondence with the insurance company, preserving all written or electronic communication and making note of who you spoke to, when, and what you discussed.

Step 2: Escalate to Your State’s Department of Insurance

If the insurer is unable or unwilling to resolve the situation, your next recourse is to escalate the complaint to state authorities. Your state’s Department of Insurance has special complaint forms available (usually on their website) for filing complaints regarding prompt pay violations. State officials will need detailed information about your claim and your correspondence with the insurance company. This is where your extensive documentation will prove invaluable. 

Protect Your Practice with Holistic Billing Services

As a medical billing provider specializing in acupuncture, massage therapy, and chiropractic services, Holistic Billing Services has extensive experience dealing with prompt payment complaints against insurers. We can walk you through every step of the process to ensure that you have all your documentation in order and are in the best position to secure the insurance reimbursement revenue (and potential interest payments) you’re entitled to under the laws of your state. With Holistic Billing’s help, you can keep your focus on your practice while we handle the ins and outs of the complaint process.

To find out what else an experienced billing provider can do for your practice and your revenue cycle management, contact our team today for a consultation.