I got another call this week from an orthopedic physician with a problem. A major insurance company was refusing to pay for imaging on their scanner. These sorts of calls are quite common. In the typical case, a group has an ambulaory surgery center, MRI or other ancillary and a payer is refusing to cover treatment there.
“Can they do that?” The answer, in most cases, is that if their contract with you allows it, they can. While a handful of states have versions of “any willing provider” statutes that may permit you to argue that an insurer must cover the ancillary, such laws are definitely the exception, not the rule. Generally speaking, if an insurer gives itself the right to limit coverage of a service in its contract with you, or if the contract with you allows the insurer to establish coverage criteria, there is little you can do about it.
Insurers are increasing placing provisions in contracts that can have a major impact on your practice. The insurer may require you to credential new practitioners before they provide any services. Historically, most insurers allowed “retroactive” credentialing. Now, any services rendered before the credentialing is complete may be uncovered. The contract may also establish rules such as a an explicit requirement that services be documented in a particular way to be reimbursable. The bottom line is that it is very import for you to know what is in your insurance contracts. While it may not be terribly pleasant to read the contract, you need to make sure that someone, whether a physician, administrator or attorney, is reviewing the contracts carefully. If the terms are not agreeable, demand revisions before signing the contract.
If you do not have a contract with the insurer, then you have far more leverage. In the absence of an agreement, an insurer has very little authority to limit coverage of a service. If an insurer with whom you do not contract attempts to deny payment for an ancillary, you should aggressively challenge them.
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