ProviderPRO.net (www.providerpro.net) includes of a growing network of independent healthcare professionals, located across the country, who are dedicated to research and education in the areas of reimbursement, coding, and compliance. The network was co-founded by two Pennsylvania entities: ProviderLAW Corporation¹ (www.providerlaw.com) and dK Coding & Compliance, Inc. (www.dkcoding.com). Both companies also serve as content providers for the network. The network is funded through two predominant services: (a) live web conferences (see, also, www.brighthought.org) and subscriptions by healthcare providers.

Team and Life Conditioning for Superteams, Inc. ("TLC") is a practice management consulting group located in Willow Grove, PA (www.tlc4superteams.com). As stated on its web site, TLC "builds superteams to achieve unprecedented results...." and "gets into the hearts of the teams and stimulates the breakthroughs that have been limiting your growth and happiness."

This advisory originally grew out of a request by TLC to review and provide information on certain non-payment issues involving Independence Blue Cross² – issues which arose when IBC reportedly stopped using a third-party company to process its claims and began to process claims in-house. For some clinics, particularly those who treat numerous IBC patients, the reductions in monthly cash flow were hugely significant. For other clinics, the reductions by themselves may not have been significant. Yet, when combined with other similar non-payment problems involving other carriers, the resulting impact was no less momentous.

As we began to review the complaints with various providers, another payment issue quickly surfaced – an issue equally significant, if not more significant, than the one just mentioned. The issue has to do with carriers in general not just "recouping" from providers, but automatically recouping from multiple patient accounts without notice and without prior opportunity to appeal.³ In one recent case, for instance, a provider reported having $15,000 recouped from multiple patient accounts without ever being notified and without ever being given a prior opportunity to appeal. In another recent case, a provider reported having $3,000 automatically recouped without notice.

Anyone who bills for a healthcare clinic can recount for you the "nightmare" that such insurance practices create from accounting perspective. Nevertheless, accounting nightmares aside, when carriers begin to recoup for any reason they wish, in any amount they wish, from any patient account they wish, and as far back in time as they wish, and, on top of that, begin to do so without notice or prior opportunity to appeal, an entirely new issue arises – an issue no less severe than a total or near-total cut-off of payment. Put another way, when every dime a provider receives is subject to "recall," how can a provider continue to do business this way and survive?

In this multi-part series, we examine the following topics: (1) what happened in the IBC crisis? (2) what do IBC chiropractors need to know from a billing and coding perspective? (3) recoupment – is a new crisis on the rise? and (4) what is the solution? I.e., what needs to be in place, at a strategic level, in order for providers to prevent (and more quickly resolve) non-payment and recoupment issues like these?

Part I addresses the first two issues. Part II will address the latter two issues.

Prior to July 2, 2005, IBC Personal Choice⁴ providers in various regions were required to submit their claims to Highmark Blue Shield⁵ for processing. On July 2, 2005, the processing of claims was scheduled to be transitioned to IBC itself (July 2nd represented the deadline for the transition). Small Problem – Highmark provided notice of the transition deadline in its August 2005 issue of "Policy, Review, and News" (PRN) – the PPO's bi-monthly publication (see below). While IBC did provide advance notice on multiple occasions, the titles of its notices did not expressly draw attention to the need for providers to change their billing practices. Moreover, many of the providers who do not regularly bill IBC directly do not receive, and did not receive, copies of IBC's publication.

When the error was finally discovered by the providers, it appears that many of them did in fact resubmit the claims, this time to IBC directly. Again, small Problem – the billing requirements of IBC did not appear to be the same as Highmark's billing requirements (see below). This led to a significant number of claims rejections and denials, a problem which was exacerbated by the fact that the claims had already been delayed in the first place.

Obviously, when we refer to these as "small problems," they're not. "Small problems" like this can have huge consequences for healthcare practices of all sizes. They can have huge consequences when they occur by themselves. They can have huge consequences when they occur in conjunction with other "small problems."

Let's return to the beginning of this Advisory. In the "Background" information, words like "ProviderPRO.net," "Network of Attorneys," "Team and Life Conditioning" appear. Anyone sense a common theme?

Who cares whether the problem is big or small. The truth of the matter is that are very few problems – big or small – that can withstand collaboration. Teamwork, which will be discussed in the last section of this series, is ultimately how these problems will be overcome..., with each team participant playing a uniquely distinct role.

Notably, Highmark Blue Shield posted the following item on pages 2-3 of its August 2005 Issue of PRN (emphasis added).

We searched through all online issues of the PRN, published by Highmark Blue Shield between February, 2004, through August, 2005, to discover whether PRN actually provided any advance notice of the transition. Unfortunately, we were unable to find any. Bear in mind that this does not mean that such notices do not exist, or that they were not provided in another fashion. It just means that we were unable to find them.

After reviewing archived copies of the PRN, we next searched all copies of IBC's publication, "Partners in Health Update," issued in 2005. A total of four relevant notices were found in the following issues: April 2005, p. 7; May 2005, p. 4; June 2005, p. 7; and July 2005, p. 9. All four notices read substantially the same. All four appear in the "Billing" subsection of the publication. The notice published in the April 2005 issue, p. 7, reads as follows:

As noted previously, IBC did in fact provide at least four advance notices in its "Partners in Health Update" publication. Unfortunately, the titles of its notices did not expressly draw attention to the need for providers to change their billing practices, instead focusing on IBC's conversion to a new computer system. Moreover, many of the providers who do not regularly bill IBC directly do not receive, and did not receive, copies of IBC's publication.

It's possible that IBC provided advance notice to providers in other fashions as well. We are just not aware, one way or another, whether IBC actually did so.

We will come back to these points at the end of our series.

We spoke at length with a provider relations manager for Independence Blue Cross assigned to the Personal Choice® network on September 15, 2005. Over the years she has provided us with helpful information on similar types of issues. She was certainly familiar with the payment issues discussed in this Advisory, and their extent, and offered a number of suggestions on billing and claims submission. We were able to confirm in writing some, but not all, of her suggestions. She conveyed to us that IBC was actively addressing the issues and they will be hosting a meeting for all participating providers and their staff on September 27th (Market Street) to discuss the issues, review changes, verify provider ID numbers, and review correct billing methods for IBC purposes. Invitations have been disbursed (apparently, you must have one to attend). For more information regarding this meeting, contact IBC at (215) 241-9333.

The suggestions are as follows:

1. CPT 97140 (Manual Therapy). The bundling denials for CPT 97140 (Manual Therapy) "have been corrected". The manager stated that this was a computer-related problem and payment corrections have been disbursed. If you have not received payment for 97140 denials by now, then you should contact your provider representative at (610) 225-9621.
2. Verification of Provider#, Group# and Tax ID# on Record With IBC – You should call IBC Provider Relations to verify that your provider and group numbers are correct. You should do this even if your claims have been paid in the past by IBC. Simultaneously, you should verify that your Provider# / Group# matches the Tax ID number that IBC has on file, and that the Tax ID number is correct. See, e.g. "Partners in Health Update," April 2005, page 10.
3. A Quick Note on the Use of the 10-Digit Provider ID# – The manager recommended that you submit claims to Personal Choice® (and Keystone Health Plan East) with your 10-Digit Keystone Provider ID#. The old numbers still appear to be valid, however by submitting claims to both networks with the same 10-digit number, it may make it easier to follow up on your claims. See, e.g. "Partners in Health Update," August 2005, page 4.
4. Verification of Provider#, Group#, and Tax ID# as They Appear on Your Claim Forms – After verifying your information with IBC as stated above, you should verify that your billing software is actually populating your claims with the exact same information, i.e., that the Provider#, Group# and Tax ID numbers match IBC's records.
5. Tax ID # {Box 25} – The Tax ID# must appear in Box 25. You should confirm that your billing software is actually populating this field with the accurate Tax ID#. See, e.g. "Partners in Health Update," April 2005, page 10.
6. {Box 33: PIN#, GRP#} – These fields must be populated. All claims must be submitted with both the group number field {Box 33: GRP#} and pin number field {Box 33: PIN#} completed. If you do not have a group number, then populate the group number field with your individual Provider ID#. See, e.g. "Partners in Health Update," August 2005, page 4.
7. {Box 24 K} – You should populate Box 24K of the CMS 1500 form with the Provider ID# of the provider who actually performed the service. This field lines up with the CPT codes and dates of service fields.

Incidentally, during the discussion, the IBC manager mentioned that not all KHPE plans are limited (by virtue of the underlying plan contract) to twenty (20) visits per year. Reportedly, the amount of visits actually allowed depends on the terms of each individual plan. Some plans may contain higher coverage limitations; others lower. Coverage limitations are not to be confused with utilization review criteria – "soft" limitations which can be overridden or rebutted with appropriate documentation (a task many providers have successfully accomplished once they have learned, and incorporated, the "legal standard of medical necessity" into their documentation). We recommend that you verify coverage limitations on a plan-by-plan, or better yet, a patient-by-patient, basis at the commencement of care.

We strongly recommend that all participating providers and their billing staff attend the September 27th meeting referenced above.

While you're at it, why not ask IBC at the meeting what its specific policies are on recoupment, i.e. what specific limitations it places on recoupment? For example, how far back in time does IBC go? Does it expand recoupment beyond the scope of a particular patient account and seek to recoup from other, unrelated patient accounts? Does it necessarily provide advance notice and prior opportunity to appeal when it seeks to recoup? How does IBC expressly deal with this issue in either its underlying health benefit plans or insurance policies, and/or in its provider manual(s)? Does IBC vary its recoupment policies on a facility-by-facilty, or specialty-by-specialty, basis? How soon could IBC provide written answers to these kinds of questions?

Just a thought.