Denials Overturned with Health Plan in Excess of $16,000.00 including Interest

Detailed Explanation of Events:

  • Our provider has been a participating provider with a particular Health Plan with their Commercial lines of business and the Medicare Advantage program for approximately 10 years;
  • Our Provider intended to treat a patient for Prostate cancer under the Health Plans Medicaid line of business;
  • Our provider was non-participating with this Health Plans Medicaid network in 2014;
  • MpowerMed’s Claim Specialist obtained, prior to treatment, a “special authorization” to treat the patient using IMRT (procedure code, 77418) with the Health Plans Medical Management department and verified our provider would be reimbursed as an out of network provider;
  • Claims for procedure code 77418 quickly denied for numerous reasons such as there was a “configuration issue” processing this code, no authorization obtained and no fee schedule set for our provider since he was out of network, and all claims with procedure code 77418 would be considered a “provider write off” per the Health Plan;
  • MpowerMed’s Claims Specialist contacted the Health Plan consistently and was continually advised all claims would be sent back for reprocessing by the Health Plans representatives and supervisors over the course of several months, as our Claims Specialist tried to work internally with the Health Plans team to resolve the issue;
  • MpowerMed’s Claims Specialist quickly filed an appeal directly to the Health Plans Corporate Headquarters without any acknowledgement, decision or response;
  • MpowerMed’s team of Specialists were aware this particular Health Plan had a documented history of Medicaid fraud wherein 2009 this Health Plan paid $80 million in restitution to avoid prosecution by Medicaid, which confirmed our position of the possible intentional obstruction for justly due claim reimbursement to our provider by this Health Plan;
  • MpowerMed’s team of Specialists scheduled a conference call with the Health Plan speaking directly to their Supervisor of Operations, and the NJ Operations Team Lead wherein they confirmed payment should have been made to our provider and all our providers (31) claims would reprocess for adjustments with interest for dates of service from 9/8/14 – 11/11/14;
  • After the conference call the Health Plan failed to reimburse our provider in the timeframe required and was negligent in providing any detailed information or communication;
  • MpowerMed’s Appeal Specialist filed a detailed comprehensive formal complaint to NJ Department of Banking and Insurance to assist this facility in obtaining justly due reimbursement for services provided in good faith to our provider;
  • An Investigator from NJ Dept. of Banking & Insurance worked with MpowerMed’s Appeal Specialist on the complaint details;
  • The NJ Dept. of Banking & Insurance communicated with the Health Plan and determined the Health Plan acted unfairly and demanded they reimburse our provider for all (31) claims for 2014 with the required interest;
  • Additionally, due to the Health Plans poor response to the State of NJ and with MpowerMed’s contribution the Health Plan is now required to provide a detailed line by line report to the State for every NJ provider affected by this issue for out of network providers for Radiation Therapy procedure codes.
  • Further, the State of NJ Banking & Insurance Department’s Assistant Commissioner was involved in providing assistance to this facility and our provider, and is currently working with the Health Plan to become compliant with all state and federal mandates.
  • MpowerMed gives our gratitude and support to the State of NJ Dept. of Banking & Insurance for their continued assistance and support to all our providers and patients.


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