Insurance Advocacy Tools and Resources

The ACR offers members a number of resources to assist with various insurance problems and inquiries. Below is a list of tools and frequently asked questions for approaching some of the most common insurance and payment issues. If you would like assistance with an issue not listed below, please contact practice@rheumatology.org. To view the current top insurance advocacy issues, please visit our current issues page.

Off-Label Drug Use Letters

These letters can be used as templates to assist in getting approval for off label uses that are common in rheumatology practice.

Pediatric Letters

Additional Resources

ACR Position Statements: The ACR issues position statements on issues that are important to the practice of rheumatology. Frequently, these position statements address barriers to patient access and may provide helpful information for securing health plan approval for a particular treatment.

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.

ACR Clinical Practice Guidelines: The ACR develops Clinical Practice Guidelines to reduce inappropriate care, minimize geographic variations in practice patterns, and enable effective use of health care resources.

Audit Programs: Information 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. This page also includes information on how ACR staff can assist with your coding and billing questions.

Medicare: Resources to assist with Medicare issues including the current Physician Fee Schedule.

Frequently Asked Questions

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 self injectables. However, some managed care organizations may require prior authorization for patients to obtain these medications.

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 determines 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%). The other reasons in order of popularity are: termination of coverage (22%), non-covered benefit (20%), other (7%) and eligibility (3%). It is important to ensure you don't submit duplicate claims and confirm all of your patients' coverage BEFORE their visits.