Setting Boundaries with Insurance Payers?
Stop “Responsibility Drift” before it becomes an avalanche!
When I discussed Ghost Networks, I mentioned that in addition to unacceptably low reimbursement, administrative tasks are another reason clinicians don’t participate in panels.
This got me thinking. Thinking is always a dangerous thing…
Sometimes, change is so gradual that you don’t realize it’s happening until one day you wake up, and the landscape is no longer recognizable.
And you think, “How did we end up here?”
One day at a time. Quietly, with no fanfare.
That’s what has happened, working with insurance companies in the last 25 years.
Do you feel more overwhelmed with admin tasks than you ever have before?
If you do, you’re not alone. I’ll be honest here: I do too! Very much so.
In January 2024, as a biller, I’m now performing tasks daily that used to be performed automatically by the insurance companies. Things that any reasonable person would consider to be the payer’s responsibility.
Yet, somehow, the responsibility has drifted onto providers and their administrative staff. Seriously, are you kidding?
These are tedious tasks that can overwhelm a biller/practice owner and divert them from your real purpose: fighting denials.
Do you, or your biller, recognize any of these?
Shuttle from one portal to another to download EOBs.
Manually post EOBs that could be posted electronically.
EAP providers: downloading authorizations and billing forms that used to be mailed or faxed to you. Or call and sit on hold to get this information.
Instead of consulting a paper reimbursement rate list sent with your contract, you are told to go to a portal to look up your rates – one code at a time.
Changing your address with a payer requires changing it with middlemen vendors as well.
Changing an address (or any practice data) requires years and multiple submissions.
Requests for anything: credentialing, EDI enrollment, claims appeals, speak to a provider network representative, need to be submitted repeatedly. Responses, if they are received, consist of:
A form that was pre-written and doesn’t apply to your situation;
Are delayed 30 days or longer
“I’ve sent your request to be addressed” – but nothing ever happens!
Dealing with a claim that was denied when in fact it was filed on time! Why? Because an electronic intermediary screwed up.
Joining or resigning from a network – and never being informed with a follow-up email, fax, letter, or smoke signal that your acceptance (or resignation) has been finalized.
Add up the time you spend on each of these tasks. It’s not a trifling amount. Time is money. Or so they say.
How many clients could you have seen, and been paid for, while you were performing these tasks?
Additionally, if you have a biller, you are paying someone to do the payer’s job … which reduces your reimbursements even further.
What is wrong with this picture?
If time is money, then responsibility drift adds up to a reimbursement rate reduction all its own.
The paper version may be called Explanation of Benefits (EOB), Explanation of Payments (EOPs), payment voucher, remittance advice, or whatever unique name the payer decides to bestow.
When it is electronically delivered, it is known as electronic remittance advice, or ERA. ERA is a file coded in the HIPAA-designated EDI (electronic data interchange) language that can be imported into any billing software.
Why am I suddenly talking about HIPAA?
Well, there’s a little-known part of HIPAA that deals with this stuff, called Transactions and Code Sets.
I promise you, this IS relevant!
The Transactions & Code Sets part of HIPAA took effect more than 20 years ago: October 16, 2003. You read that right: 2003.
If HIPAA standardized this all 20 years ago, why do I have to go to various portals to download and manually post things?
That’s the million-dollar question. Or rather, hundreds of millions of dollars.
During the first decade of Transactions and Code Sets, ERA’s were the order of the day. We enrolled; they arrived. Whether a provider chose to enroll separately in EFT was an independent decision and the finances were an independent transaction.
Then, in 2014, part of the ACA mandated that health plans had to offer electronic payment transactions. But the language of the ACA left holes large enough to drive a tractor-trailer through.
Overnight, a whole industry developed. Funded by venture capital, these were middlemen who came up with schemes designed to profit from healthcare payments… At your expense.
Ever received one of these with an EOB?
Of course, you have. What I’ve just described for you is the origin of the Virtual Credit Card (VCC).
I first encountered these 10 years ago – in 2014. Now, almost 60% of practices are reporting having to pay fees to get paid at least some of the time, according to an investigation by ProPublica from August 2023.
In the spring of 2023, I attended an Optum virtual event, where they reported that over $1 billion was redeemed in 2022 via VCC’s. Assuming a merchant fee of 3%, that’s a staggering $30 million of YOUR income being re-diverted back to United Healthcare and Mastercard/Visa. (if I’m calculating all those zeroes correctly…)
But VCC is just the tip of the iceberg.
Hopefully, everyone knows by now that you can call to opt out, and that –eventually, with enough persistence– they’ll send you paper checks.
You can also sign up for electronic funds transfer, but for a couple of the middlemen, notably Zelis and ECHO, these EFT “services” cost 2.5-3%. They “justify” these fees, saying they aren’t directly for the EFT, but for the “value-added” services, such as portals, and a single enrollment for a huge stable of subscribing insurance payers.
It’s less well-known, but you can get out of the fee-based EFT also. There are problems, however. Serious ones – that end up drifting responsibility over to you.
Zelis and ECHO punish EFT fee objectors by forcing repetitive payer-by-payer enrollments.
Question: Tell me why it’s necessary to send in the same information for every single payer they represent. Your TIN, NPI, address, and bank account are the same. |
Answer: Because these companies are correctly betting you’ll forfeit the percentage of every reimbursement to avoid having to enroll multiple times!
Solution:
Since your TIN, NPI, address, and bank account are the same, just copy the form as many times as you need to, changing only the information that relates to the specific payer in question.
Let’s drown them in a paperwork mess of their own making!
- Zelis does not allow ERA service for EFT fee objectors. The ONLY way to receive remittance information if you refuse to pay their EFT percentage, is to manually go to their portal, download pdf copies of EOBs, and manually post.
This seems a clear violation of 45 CFR § 162.925(1) – but they get away with it, because of the close ties between the Centers for Medicare & Medicaid Services (CMS) and the chief legislative affairs officer at Zelis, Matthew Albright, as described in the ProPublica article.
The group is bipartisan – three Democrats, three Republicans. The fate of the No Fees for EFTs will be a significant development (or setback) in our industry in 2024.
- ECHO doesn’t suppress ERA in quite the same blatant way as Zelis. However, in 2020 they found another method of diverting responsibility while at the same time making millions in profit.
They use Deluxe Payroll to deliver “MPX” checks, which are checks you download and print, and then deposit the same way you would a check that was mailed to you.
