In an effort to assist our members with insurance problems and inquiries, this portion of the ACR website contains various types of insurance information and resources. These resources include insurance letter templates, auditing resources, the ACR Health Plan Complaint Form and much more.
- Health Plan Complaint Form—In an effort to better assist the membership in addressing both individual and system wide insurance issues, the ACR has developed a standardized complaints form.
- Letter Templates—Members can use the ACR templates letters to generate responses to insurance carriers.
- Medicare— information such as medicare fee schedules, information about medicare part D, and letter templates relating to medicare issues.
- Model Biologics Policy— The ACR's Model Biologics Policy can be used nationwide to reduce administrative burden among rheumatologists, patients and insurers, and allow physicians to properly treat patients without administrative delays. In an effort to make sure that the best care is provided to patients, the ACR has developed a standardized prior authorization form.
- The Recovery Audit Contractors—developed by the Centers for Medicare and Medicaid Services in an effort to ensure correct payments to providers and suppliers in the Medicare Fee-for-Service program.
If you have any further insurance questions or issues, please contact the Practice Management Department at (404) 633-3777
The Insurance Subcommittee of CORC was created in 2009, and has been proactively functioning since with approximately 10 members recruited by the ACR staff as well as 2 ACR staff members. This subcommittee's purpose is to coordinate and engage in all activities that improve the practice environment of rheumatology as it is affected by health insurers; including: patient access to high quality care and treatment, reimbursement, regulation, and reviews of various drug and treatment policies.
If you have an insurance issue, please do not hesitate to ask for the Insurance Subcommittee for help! The Insurance Subcommittee cannot negotiate contracts for physicians, but are willing and able to investigate unfair practices from insurance companies that would put a patient at risk from their disease. Please fill out the Health Plan Complaints Form regarding your insurance issue, and the Insurance Subcommittee will do its part to assist you.
Insurance Subcommittee Members 2013-2015
Elizabeth Perkins, MD- Chair
Robert Jenkins, MD, PhD
Jennifer May, MD
Paul DeMarco, MD
Fredrica Smith, MD
Jose Pando, MD
Meera Oza, MD
Alan Erickson, MD
David Goddard, MD
Joan Senteney, PA
Nilsa Cruz, BS
Antanya Chung - ACR Staff
Melesia Tillman – ACR Staff
Members wishing to volunteer for the ISC should complete the following Insurance Subcommittee application.
If you have any further questions about the Insurance Subcommittee, or would like to join this subcommittee, please contact Antanya Chung.
Frequently Asked Questions
Also read our FAQs on Medicare.
Is there a place where I can find out what procedures and laboratory tests are covered by private insurers?
Private insurance carriers sometimes maintain policies similar to Medicare policies on their Web sites. However, unlike Medicare, private plans are not required to keep their policies available through their Web sites, so phone calls to provider relations and payment representatives are often required. Additionally, private insurers categorize these policies under different names such as Medical Policies, Medical Coverage Rules, etc.
Private insurers communicate many of their medical policy changes via newsletter so it is imperative that your practice keeps current on this literature. They will also refer you to a certain newsletter if you call to ask about a policy so it is also important to keep these in order and accessible.
If an Insurance Company pays for services rendered by Doctors Office, yet does not post and cash check until after patient has moved on to a new plan, is patient still responsible for original payment?
The doctor's office must file the claim with the eligible insurance carrier at the time of the visit. The relevant information is the patient's eligibility on the date services are rendered. If the doctor's office does not file a claim within the filing timeframe, the patient is not responsible, hence, the claim will need to be written off. However, once the claim is processed and payment release to provider the patient is responsible for any patient responsibility (e.g. deductible, copay, out of pocket expenses). The practice should require all patients to complete a financial responsibility form.
How long does a company have to pay a medical claim?
The insurance company has 45 days to either pay or deny a claim once proof of loss has been received, unless additional information is requested.
Can you bill the patient for cancellations?
Yes, the physician can charge for this as long as all patients are subject to the cancellation fee. Also the notice should be displayed prominently in the office where patients can see it.
Do private health insurance companies cover and reimburse for self injectables?
Many private plans cover and reimburse for ENBREL. However, some managed care organizations may require prior authorization for patients to obtain ENBREL.
How do I know if my practice is collecting payment from insurance companies in a timely and successful manner?
All practices should be using aging reports to measure their collection cycles, rates and accounts that need to be followed up or turn to collections. Aging reports are used to compare your collection rate cycle (e.g. 30, 60 90 days) as well as, billing/coding errors and insurance reimbursement trends. The amount of monies in each of these brackets determine the urgency for each to be worked before claims are denied for untimely filing.
Why do I get so many denials from insurance companies?
Based on the Health Insurance Association of America's survey in 2003, the top reason insurance companies deny a claim is because of duplication (48 percent). The other reasons in order of popularity are: termination of coverage (22 percent), non-covered benefit (20 percent), other (7 percent) and eligibility (3 percent). It is important to ensure you don't submit duplicate claims and confirm all of your patients' coverage BEFORE their visits.