Healthcare organizations and payers, large and small, are on the brink of full 5010 implementation.
One of the touted benefits to both the healthcare providers and payers of 5010 is more detailed data useful for emerging reimbursement models.
A number of healthcare organizations, particularly specialty and subspecialty providers, have identified a recent spike in requests for supplemental billing detail such as itemized statements. Minimizing routine requests for itemized billing detail is just one goal of 5010. However, due to the payers extensive testing of 5010 and how 5010 data may be used to change reimbursement methodology, providers may be seeing a spike of requests this quarter.
If the requests for information appear to far reaching, you may want to respond in writing with a request for clarification. Appeal Solutions has developed a sample letter for responding to overly broad requests for billing detail:
Dear Payer,
Your company has submitted a request for itemized statements related to the claims listed above (list all involved claims). Due to the number of requests received, we wish to request more detailed information regarding your company’s claims review process and the need for itemized billing information.
Please be advised, our organization has a contract with your organization effective for these dates of service. Our review of the applicable contract does not contain language related to use of the itemized statement for benefit calculation. It is unclear how the itemized statement is being reviewed, the credentials of the billing detail reviewer and the methodology which requires extensive use of itemized details. Therefore, we request a detailed explanation regarding the multiple requests so that we may respond appropriately.
As you are likely aware, both state and federal disclosure regulations require insurers to justify any payment reductions with specific information from the policy or plan document. Enclosed is a copy of the Assignment of Benefits signed by (patient). This assignment specifically grants our office the rights to all benefits and all interest and rights, including causes of action and the right to enforce payment for services rendered under any insurance policy or plan. As legal assignee, our office has full rights to the specific data used in making benefit determinations, including fee schedules, methodologies and bundling formulas.
If benefits remain denied, please provide the information requested to substantiate the itemized statement requests, including the specific use of this information and the credentials of the reviewer assigned to conduct detailed billing review.
Sincerely,
(your organization)
This letter may be customized for your organization to cite contract specifics applicable to claims processing. For more information about developing more protective contract language and/or using contract language in appeals and requests for information, contact Appeal Solutions at 888-399-4925.
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