Winning an Insurance Audit Appeal!

I WON an Overpayment Recoupment for mental health services from Blue Cross Blue Shield! And I’m sharing what I did in case you find yourself dealing with the same thing.

I got the dreaded insurance recoupment letter from BCBS saying they overpaid me (over $1700) and demanded their money back. They provided a link in the letter to get additional information, but it was broken!  I could appeal by mail (“… the address to send an appeal is provided below.”), but the due date was in just 10 days.

I wasn’t concerned about the quality of my documentation, but since I didn’t know why they overpaid me, I couldn’t write a coherent appeal.  Upon close reading of the letter, I realized that the recoupment dates were for sessions that I’d provided over a year ago.  The statute of limitations for Massachusetts is 1 year.  Insurance companies can only go back for one year whether it’s for overpayment or a medical necessity audit.

Here’s the bottom line of my phone calls: 

1. BCBS National recoupments are for 2 years for all providers.
2. Representatives do not know that there are state laws that supersede BCBS National regulations.
3. Know your state’s statute of limitations!  (I’m from Massachusetts.  The MA law limiting recoupments to 1 year is for mental health providers.  It is not for other providers.)  
4. Make sure you say you’re a mental health provider.  Otherwise, you will likely be given inaccurate information.  Just because you provide your license and NPI number doesn’t mean the representative knows you’re a psychotherapist.  They probably don’t.

This process included wrong telephone numbers, multiple useless automated phone cues, and multiple assurances that I was getting accurate information when I wasn’t.  (That doesn’t include the time I spent on their website.)  Despite me mentioning it several times, no one recognized the Mass. General Laws c.118E § 38A, which is the bill that limits clawbacks to one year (except in the case of fraud).  Once I got a thoughtful supervisor on the line who was willing to listen and think about what I was saying, I got a swift resolution in my favor.  The recoupment was wiped out immediately with what sounded like a real apology for the inconvenience and without me having to do anything more.  

FYI – I elicited a promise from this supervisor to please educate their representatives about the difference between the national and state statute of limitations because chasing down this information took hours and makes me and many other therapists who endure the same aggravation want to leave the panel.

Some encouragement for taking care of yourself through an insurance audit appeal…

1. When something does not make sense to you, it’s because it doesn’t make sense. Trust yourself when you question what the heck is going on.
2. If you feel invisible, it’s because the representatives are working from a decision tree. They are not taught to truly listen and respond to anything that does not fit into their understanding outside that tree. Supervisors have access to a wider screen and see more in depth subscriber information.
3. Ask or demand to speak with a supervisor. The reps will often feel intimidated when asked to speak with a supervisor and insist that you’ll get the same answer. Don’t let your yourself be bullied or gas lit, which happens when a person feels threatened. Remind them, “This is not a personal failure on your part. I would still like to speak with a supervisor.”
4. Come armed with all the information that could possibly be wanted: your license and NPI #s, the client’s name, DOB, dates of service, insurance #, the name of the person insured and that person’s DOB. Without this information, the representative will not be able help you until you provide it. If you’re in MA, get a overview of the Mass. General Laws c.118E § 38A click here. Having this bill in my possession provided the assurance I needed to persevere. 
5. Be brave!  Take deep breaths to keep yourself from either screaming in frustration or withdrawing in terror. (Even I began to question myself.)

BCBS CONTACT NUMBERS

Provider Services: 800-443-6657 #5.  Listen for all the prompts!  And while you’re waiting, have something else to do because it takes a long time to get someone on the phone.

Coordination of Benefits: 888-799-1888.  This is a direct number.

I spent over 4 hours dealing with this on the phone. That doesn’t take into consideration the time I spent talking myself down and looking for contact information.  I’m exhausted.  But happy about a good outcome. And happy to share it with you.

If you are concerned about an audit, the state of your notes, or mental health documentation in general, consider taking Beth Rontal’s online documentation training.  You’ll learn how to protect yourself from clawbacks, pass audits, and translate your clinical intuition into the behavioral language required by insurance companies.