A Sampling of Past Physician Advocate Success Stories
Michael J. Rensink, MD, SDCMS-CMA member since 1979, had an issue getting paid for parts of a surgery he performed on one of his patients who is insured by United Healthcare (UHC). UHC argued that there was a “supposed surgical date” that was not kept, and that they were never notified about the change for the surgery date. There was never a proposed date for surgery given by Dr. Rensink’s office because they do not schedule surgeries until they have the authorization in hand. The procedure that was performed in this surgery requires a prior authorization, and his office did have all of the paperwork showing the approval for the authorization. UHC ended up partially paying for the claim but did not pay for the procedure. Dr. Rensink tried to appeal on his own, to no avail — he even tried to speak to a supervisor at UHC, but with no success. He reached out to SDCMS, and, with the help of CMA’s Center for Economic Services team, Dr. Rensink’s denial was overturned, and he was paid for the surgery.
A two-physician pediatric group had difficulties with Medi-Cal’s stopping payments on their checks because of a change of address form that was lost in the shuffle. Through CMA’s Economic Advocacy team, the change of address form was expedited to avoid any further delay in payments.
A medium-size orthopedic group had multiple problems with Medicare, such as refunds, credentialing of physicians, and lost paperwork. The practice contacted Palmetto several times and received conflicting courses of action to remedy their issues. Through SDCMS’ Palmetto contacts, we were able to communicate to the practice exactly what was needed; their Medicare checks started flowing again, and everything got squared away.
A solo psychiatrist noticed a marked increase in Anthem Blue Cross’ repeatedly denying payment of psychiatric medications in doses that are above package insert but well within the standard practice of care. The physician attempted to appeal these denials on her own to no avail. CMA’s Economic Advocacy team connected with the pharmacy division at Blue Cross through their contacts, and the denials were overturned.
A solo surgeon had an outstanding claim with Health Net. It had been denied and appealed several times, and the practice had no other solution to the problem. At the time, the physician was not an SDCMS-CMA member. In talking to another physician who is a member, the surgeon decided to join in order to see if CMA’s Economic Advocacy team could assist with the issue. CMA’s team was able to get the claim paid, with interest, which paid for the cost of the physician’s dues and then some: $6,800.
A two-physician oncology group ran into several obstacles with their Medicare credentialing. Their NPIs were not linking, and every time they contacted Palmetto, they received conflicting answers as to what they needed to do. During this time, Palmetto held all of their claims, and there was no money flowing into the practice for Medicare patients. SDCMS was able to work with Palmetto and communicate to the practice exactly what was needed to get them squared away. Palmetto quickly released $114,000 in back claims.
“As a byproduct of reengineering our practice, we learned how best to incorporate SDCMS’ and CMA’s support resources, body of knowledge repositories, and key program initiatives into the framework of our updated business model and practice management structure. We have gained economies in areas not seen before, and, through participation in SDCMS’ seminars and engagement with CMA’s Center for Economic Services, we have significantly improved our revenue cycle management efforts. We have accomplished this with the use and adoption of CMA’s Best Practices, Back to Basics, and Taking Charge publications, allowing us to create and sustain a balanced scorecard for our practice.” — Solo Physiatrist SDCMS-CMA Member
A medium-size cardiology group had a terrible time when Palmetto took over as the intermediary for Medicare. This affected their entire group, including their allied health professional staff. Through our contacts at Palmetto, we were able to fix all of the outstanding issues for the practice, and their reimbursements began flowing again.
A solo allergy and immunology physician, who was new to the area and in her first few years of practice, had questions about billing practices. SDCMS was able to educate her and provide her with the information she needed to prevent her from potentially adopting illegal billing practices in her office.
A solo dermatologist got yelled at by one of her patients because the physician would not refill the patient’s prescription without seeing the patient first, as it had been almost over two years since the patient had last been seen. The prescription was a non-schedule II–V drug, and the physician wanted to make sure her prescription refill practices were correct. SDCMS was able to provide her with the legalities of refilling prescriptions for non-schedule II–V drugs, and she thanked us for confirming with her that her prescription refill practices were appropriate for her practice.