Monday, 6 of May of 2013

Third Party Reimbursement

From 2004:

Legal Arguments Available to Speech-Language PathologistsConcerning Payment for their Services

On April 1, 2004, Terri Philpot, Lynne Harmon, and John Williams met with Paula Flowers, Tennessee Commissioner of Commerce and Insurance, to discuss the problems that speech-language pathologists (SLPs) have experienced in getting paid by insurance companies for their services. Commissioner Flowers suggested that we consider the following legal avenues to address these problems:

1. Tenn. Code Ann. 56-7-2603. This statute, passed by the General Assembly in 1988, provides:

56-7-2603. Treatment by licensed audiologists or speech pathologists.(a)(1) Notwithstanding any other provision of the law to the contrary, any insurer providing individual, franchise, blanket or group policy of insurance issued pursuant to this title which provides hospital expense and surgical or medical expense insurance and/or which is entered into, delivered, issued for delivery or renewed in Tennessee after January 1, 1989, shall offer to provide benefits for expense of residents of Tennessee covered under any such policy or plan arising from conditions or disorders of hearing or conditions or disorders of speech, voice, or language, so long as such conditions or disorders receive treatment from duly licensed audiologists or speech pathologists, as defined in 63-17-103. (2) The provisions of this section are applicable to all health benefit policies, programs, or contracts offered by commercial insurance companies, non-profit insurance companies, prepaid plans (health maintenance organizations) and to all health benefit programs provided state government employees. (b) Nothing in this section shall apply to any insurance policy which only provides coverage for specified diseases, hospital indemnity, medicare supplement or other limited benefit coverages. (c) Notwithstanding any provision of this section to the contrary, the provisions of this section shall be construed to apply to the state and its political subdivisions. [Acts 1988, ch. 970, 1-3; 1992, ch. 984, 4; T.C.A., 56-7-1011.]

This statute does not guarantee any particular level of payment for SLP services, nor does it guarantee that a particular SLP will be included as a provider in a particular health insurance plan. But it does require all health insurance polices and plans (except federally exempt self-insured plans) to provide payment for services provided by SLPs and audiologists.

2. River Park Hospital, Inc. v. Blue Cross Blue Shield of Tennessee, Inc., 2002
WL 31302926 (Tenn. App. 2002). The Tennessee Court of Appeals ruled in this case that Blue Cross must pay River Park Hospital (a McMinnville hospital) a reasonable rate of reimbursement for emergency room services provided to Blue Cross enrollees who sought treatment at the hospitals emergency room. Under federal law the hospital was required to provide those emergency room services, even through River Park Hospital had chosen not to renew its contract with Blue Cross because of Blue Cross low reimbursement rates. Blue Cross said it would pay the hospital its in-network rate for the services provided to these patients. The Court of Appeals sided with the hospital and held that Blue Cross must pay a reasonable rate to the hospital rather than the lower rate paid to in-network providers. A key to the Courts decision was that the hospital could not refuse to provide services to the Blue Cross enrollees because of the requirements of federal law governing emergency room services. SLPs might be able to rely on this case as a legal precedent to the extent they are providing services mandated by federal law.

3. Blue Cross entities in other states. SLPs should try to determine, perhaps with ASHA’s help, what the Blue Cross entities in other states are paying for specific services provided by SLPs. Each state has a Blue Cross entity, but they are separately managed and the rates paid by each entity vary. Blue Cross Blue Shield of Tennessee is not obligated to pay the same amount for a particular service as is paid by Blue Cross entities in other states, but it provides a persuasive argument if Tennessees payment amount is much lower than that paid in other states.

4. Filing a complaint with the Tennessee Department of Commerce and Insurance. The Department has limited authority to redress many complaints, but it may have leverage to persuade insurance companies to correct abusive practices. Commissioner Flowers said that the person to call in the Department is Stephani Lassiter, of the Consumer Insurance Services Group, who may be reached at 615-741-2218, or at stephani.lassiter@state.tn.us.

5. Tenn. Code Ann. 56-8-104. This statute prohibits insurance companies from engaging in unfair methods of competition and unfair or deceptive acts or practices. This statute prohibits things like false information and advertising, false statements, etc. Tenn. Code Ann. 56-8-108 gives the Commissioner the authority to convene a hearing to determine whether a particular act or practice violates Tenn. Code Ann. 56-8-104 and whether to issue an order that the insurance company cease and desist from the act or practice. SLPs may wish to utilize this procedure by complaining to the Commissioner and asking her to convene a hearing to consider whether a particular act or practice is false or deceptive.

6. Meet with Blue Cross CEO. The CEO of Blue Cross Blue Shield of Tennessee is Vicky Gregg, a registered nurse by background. Commissioner Flowers suggested that TAASLP attempt to set up a meeting with her to discuss the concerns of SLPs. Another point of contact might be Bill Young, Blue Cross general counsel, who formerly worked for THA and for Vanderbilt Medical Center.