Collections 101

This is not legal advice – it is just how I do things.

So you’ve done all of the work – driven out to the office, completed the clinical interview and exam, reviewed the records, written your opinions, and served the reports. If you’re using QME Companion, you’ve billed electronically.

One or two weeks later you’re checking your mailbox. You see with excitement there is a letter from an insurance company. You start thinking, “Oo I wonder which case this is for”. You open the letter and your heart sinks. It’s a denial. There is some whacky excuse like “the claim was adjudicated as non-compensable” or “the charged amount exceeds the medical-legal fee schedule.”

When I was a newer QME, I remember thinking, “was my report that bad?” It’s funny looking back at that now. Rest assured, it has nothing to do with your report. I can’t speak to why it happens – I don’t know what happens in the minds (or computer systems) of the payor. The question is, what do you do now?

Don’t panic. You will be irritated, maybe even angry, but don’t let it get the best of you. Here are the major scenarios and what to do.

No Response

The payor is required by law to issue an EOR (explanation of review) and pay you within 60 days of receiving the bill. If I don’t get any response, I serve (via mail) a one-page letter (with also attaching the original report and bill). The letter is titled “Objection and Final Payment Demand” (contact me for my template). It should go to defense counsel and the insurance company/adjuster. Before QME Companion, when I billed with mail rather than electronically, I would use Priority Mail so that I could have tracking and prove that the report was delivered to the adjuster. In those days, I would attach a pdf of the tracking information from USPS as well. With electronic billing, a screenshot from QME Companion does the job.

If they do not respond in another 60 days, I send the documents to Brett (my attorney of choice), who will file a petition and collect the original billed amount plus 10% penalty and 7% annualized interest. There is no cost to me, as the insurance company must also pay his legal bill. Be patient here, as it can take several months to get a petition hearing on calendar. However, some payors will receive the notice of petition, and pay before it gets to a hearing.

Full Denial

You receive an EOR showing what you billed for, but payment is denied. In this case, you have two options. You can immediately file a SBR (second bill review, a few clicks in QME Companion), or you can wait until 60 days have passed from your initial submission, and send a Non-IBR Objection and Final Payment Demand.

If you choose to send an SBR, they are required to respond within 14 days. Sometimes, they will go ahead and pay you. Other times, they will double down and send another EOR denial.

If they don’t respond within 14 days of your SBR, or if for any reason they have not paid within 60 days of the original submission, you serve (via mail) the one-page “Non-IBR Objection and Final Payment Demand” letter, along with a copy of your report and bill, and the EOR, to the payor and defense counsel. If they do not pay within 60 days, I send the files to Brett (my attorney), so he can file a petition.

What About IBR?

The astute reader may have noticed that the letter used in the scenario above was titled “Non-IBR Objection and Final Payment Demand”. Why this designation? The IBR system is used “where the sole disagreement is the payment amount under the medical-legal fee schedule.” The above scenarios do not involve payment amount – it’s a total denial of payment. This is why it can be litigated outside of the IBR process with a petition.

So when is IBR appropriate? The two main scenarios I have come across are:

1. Billing Errors (With QME Companion, I don’t need to worry about these anymore)
   1. Partial payment for a record review charge. This occurred when I was manually filling out the CMS-1500 forms and did not put the number of “units” next to the charge.
   2. Leaving out the cents on the CMS-1500 bill (this led me to getting paid $13, instead of $1300 on a supplemental, because I put $1300 instead of $1300.00 on the bill)
2. Interpreter fee: Not getting paid the extra $201.50 for an evaluation that required an interpreter. This happened once and I let it go.

I’m sure there are other scenarios, but, as you can see, the scope of IBR by the letter of the law, is limited. And if you have an attorney that is willing to file petitions with no charge, you don’t need to rely on the IBR process (which charges you $195 to file up front, and does not recover the required penalty and interest).

So there you have it. Getting a denial can be frustrating and stressful, but managing a Collections process is not rocket science.