Recently, home infusion pharmacies have faced formidable challenges stemming from underpayment, untimely payment, and non-payment by major medical plans for infusion therapies. This pervasive issue affects both in-network and out-of-network providers across the healthcare industry, with reports suggesting that insurers, such as Anthem, are withholding billions in approved but unpaid claims. In this article, we aim to illuminate the tactics employed by health insurance companies to circumvent payment to home infusion providers. Additionally, we will explore the legal tools available to empower home infusion pharmacies in challenging payment discrepancies and safeguarding their rights.
a. In-Network Providers
i. Denials/Requests for More Information
Health insurance companies frequently deploy denials or requests for additional information to impede or delay payment to in-network providers. This tactic places a burden on home infusion pharmacies, forcing them into a cycle of gathering information to counter denials or respond to ambiguous requests.
ii. Contradictory Acceptance or Rejections of Materials
Inconsistency in accepting or rejecting documentation creates hurdles for in-network providers. Insurance companies may accept certain information on one claim but reject it on another, adding complexity to the payment process and hindering timely reimbursements.
iii. Changes in Payor Position on Terms
Sudden shifts in payor stances on contractual terms introduce confusion and financial uncertainty for home infusion pharmacies. Changes in interpretation and application of contracts can lead to the denial of payment for services that were previously covered.
iv. Third-Party Intermediaries
Contracting with third-party intermediaries adds a layer of complexity, with differing interpretations of contract terms and potential loss of network access for providers previously contracted with the health plan.
v. Patients with Out of State Coverage
Health insurance companies create obstacles for contracted, in-network providers treating patients across state lines or with out-of-state coverage, leading to delays, confusion, and non-payment.
b. Out-of-Network Providers
i. Non-Payment
Out-of-network providers face outright non-payment of claims, exploiting limited recourse options for challenging these actions efficiently.
ii. Gross Underpayment
Insurers may technically approve out-of-network claims but issue payments well below market rates, posing challenges for providers seeking to challenge these actions.
iii. Issuing Payment Directly to Patients
Even when payments are made for out-of-network claims, insurers may intentionally send payments directly to patients, placing the onus of collection on providers and leading to partial or non-payment for services rendered.
a. Prompt Pay Laws
Leveraging prompt pay laws can be instrumental, setting timeframes for insurance companies to process and pay claims, ensuring timely reimbursements, and imposing statutory interest for delays.
b. ERISA Laws
The Employee Retirement Income Security Act (ERISA) offers legal recourse for home infusion providers when insurers violate their obligations. Beneficiary appeal rights, claims processing regulations, and private rights of action can be employed to address violations.
c. Contractual Provisions
Reviewing and negotiating favorable contractual provisions can clarify payment expectations, establish coverage and rates, and incorporate state payment and appeals requirements, providing home infusion pharmacies with additional leverage in case of payment disputes.
Conclusion
Home infusion pharmacies, facing the multifaceted challenges posed by unjust insurance tactics, can strategically employ legal tools to protect their rights and secure fair compensation for their vital services. By understanding and navigating these legal avenues, providers can navigate the complex landscape of payment discrepancies and emerge resilient in the face of adversity.