Stop PREMERA from denying your healthcare
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Over the past few years employees have seen their benefits decline, health care providers have seen reimbursements decline, and employers have seen their healthcare costs skyrocket. Insurance is not getting better it is getting worse! However, there is one organization that has profited tremendously during this time, Premera Blue Cross. They have benefited from record profits while everyone else suffers! Thats right, the middle man profits while everyone else gets punished.
For the last few years, Premera Blue Cross has placed our clinic and many others like ours on "Prepayment Review".
What is "Prepayment Review"?
"Prepayment Review" is when an insurance payer wants to review a doctors claims before determining if they will cover a healthcare service that may be medically necessary. Many insurance payers do this from time to time temporarily to determine the following:
1) Was the service that was billed, actually rendered?
2) Does documenation support the service provided?
Most Insurance payers will use "Prepayment Review" for a handful of cases temporarily without much interruption in claim processing unless they suspect fraud or some type of wrongdoing. (extremely rare)
Premera on the other hand, uses this tool illegally, as a weapon to deny healthcare for their members. They falsely tell their members that they are covered for certain healthcare services, only to deny claims and leave patients with large bills once they "deny" claims due to "Prepayment Review". They will always leave a vague reason such as "the documentation did not support the service rendered" etc.
As an example, You decide to accept an offer and start a career at Microsoft, Amazon, Starbucks, Expedia etc. One of the key factors in your decision to begin employment with this organization is the great insurance coverage you "think" you are getting. One day you decide to get a massage since you have neck tension from working long hours. You decide to use your insurance that you are paying for. The Health Provider you ultimately choose is under "Prepayment Review". This service will most likely get denied for "lack of documentation". This is just a tool for Premera to not pay for medically necessary treatments and they have been getting away with it for almost a decade.
I have personally seen dozens of doctors and clinics undergo this abuse over the last few years. It is predictable and always follows the same path:
1) Premera will conduct a chart review (audit) of a handful of patient files
2) If they determine that the doctor or clinic is popular (costs Premera shareholders profit) they will put that entire clinic on "Prepayment Review" indefinitely.
3) Now the doctor has to submit all of their paper documents to be considered for reimbursement. This is an extremely tedious task and requires the doctor to hire full time staff just to print these thousands of documents since they can no longer submit them electronically. (Our Doctors stay at the office until 9:00pm most nights knowing that their chart notes will most likely kick back anyways)
4) The majority of these claims do not even get looked at for at least 90 days and when they finally get reviewed they are denied for "insufficient documentation" by a coder that is most likely bonused for denying claims. (Washington State law states that these claims have to be processed within 30 days). Patients are always welcome to look at their chart notes and decide if they think there is sufficient documentation. If you would like to do this, please ask us.
5) The doctor is then told that they can appeal the claims which will take another 90+ days and most likely be denied once again. Please imagine the amount of work a health provider has to go through to get paid for a $30 claim.
6) If the healthcare provider tries to fight back then Premera will always kick them "out of network"
As many of you have probably already noticed, over the last few years more and more doctors are starting to go "out of network" with Premera. Essentially what happens is that the best and most popular doctors (the most costly to Premera) either stop accepting Premera or get kicked "out of network" for fighting back. It is dangerous for us to allow an Insurance Payer to dictate how you should use the healthcare you are entitled to.
Please do the following if you would like to continue having access to the healthcare you deserve:
1. Sign the petition
2. Forward to friends, family and co-workers (anyone affected by this decision)
3. Post the poll link on professional or social platforms.
4. If you work in benefits, or know someone who does, please email us their contact information so we can forward the results of this poll directly to them.
5. If you notice that your healthcare services are being denied on your "explanation of benefits" please do the following immediately:
A. Report this to your HR team
B. File a complaint with the Office of Insurance Commisioner (OIC) at the following address www.Insurance.WA.gov
The most common denial codes you will see are:
B53 "After reviewing the available medical records, it was determined that the records do not support the billed procedure code."
OA-B1: "Non covered visits. Start 01/01/1995"
These are the generic codes they will use to deny reimbursement. Patients are always welcome to review their medical records to determine their validity. We have had our medical records tested by many professional coders who have all determined that they are clear and compliant.
Help us continue providing the best healthcare in Bellevue. The Bellevue community deserves a convenient. hassle-free healthcare experience while coping with work stresses that are epidemic in the modern tech world. Don't allow corporate greed to dictate when you can utilize the healthcare you have worked so hard to earn. Anyone who has ever been to our clinic knows we always hire passionate, honest hardworking, patient centered staff. Help them get back to doing what they love..... SERVING OUR PATIENTS AND COMMUNITY
If you would like the entire story please do not hesitate to contact our CEO Raymon Kooner at firstname.lastname@example.org
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