BHE Podcast, Episode 030 — Anelia Shaheed, JD, Esq, Partner at Law Offices of Julie W. Allison
At the East Coast Symposium on Addictive Disorders August 19-21 in Baltimore, Anelia Shaheed, JD, Esq, a partner at the law offices of Julie W. Allison, presented on the topic of avoiding reimbursement claim denials and providers’ legal rights. Shaheed joins the BHE Podcast to share some basic steps and resources for provider organizations looking to avoid claims denials by health insurers, as well as what providers need to do before filing a lawsuit for reimbursement.
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Tom Valentino: Hello, and welcome to the Behavioral Healthcare Executive Podcast. I am BHE Digital Managing Editor Tom Valentino. We are joined today by Amelia Shaheed, who is a partner at the law offices of Julie W. Allison. This weekend at the East Coast Symposium on Addictive Disorders in beautiful Baltimore, Maryland, Amelia is presenting on the topic of avoiding reimbursement claim denials and your legal rights as a provider. Amelia, thanks for making the time to join the BHE Podcast.
Amelia Shaheed: Hi, thanks for having me.
TV: Absolutely. Tell us a little bit about the work that you do at your firm.
AS: Well, our firm is a really specialized healthcare firm. All we do is work with providers, hospitals, and doctors in the healthcare field for all areas. I actually had a little bit of an interesting background prior to getting my law degree. I worked for a medical billing company dealing only with substance abuse. When I transitioned to law, I stayed in the healthcare field and with the issues of reimbursement. So, I'm able to offer a very unique perspective as a lawyer, I'm able to help explain things from both the billing side—seeing it operationally and what actually happens—and then also from an attorney's side about what your rights are and how to avoid the traps that a lot of people fall into with insurance.
TV: What are some basic steps that providers should be taking to avoid claims denials by health insurers? Because obviously this is a hot button issue for providers and our listeners. What kind of steps can be taken there?
AS: Well, what I like to tell my clients is, it's a process. It's an overarching process. It starts from even before you submit your first claim. You need to know and have processes in place to check each point of the claim submission from the time the patient comes in the door to make sure you're checking the benefits correctly, for the utilization review process making sure you're having qualified people provide services, medical record documentation—super, super important—making sure you're documenting to what the insurance companies expect. And then on the back end, checks and balances on claims. Are claims going up correctly? Are denials being followed up on? So, it really is an overarching process that starts from day one to ongoing throughout your history. I always like to work with my clients to help them understand, because if you have a good system and you have checks and balances in place, you aren't going to run into insurance issues.
TV: Are there some tools and resources that you would recommend to help avoid denials?
AS: Definitely having your own checklist as to who is auditing medical records. All the insurance companies publish what are called guidelines for medical necessity. It's a great place to start, and sometimes they vary by insurance company. So, what one may require for detox is different than what another may require for the same level of care. Having and reviewing those checklists from the insurance companies is super important.
The other thing that's published and that's out there [is] what's called “reimbursement policies.” All insurance companies publish that. And they will tell you, this is how we expect you to bill. This is what we would expect you to put on a claim. These are the boxes we want billed. And they're publicly free tools that are published by the insurance companies so that you do submit the right claim. I highly, highly recommend that all your clients become familiar with those tools and go on the websites and learn about how to access them.
TV: If providers reach a point where they feel they need to file a lawsuit for reimbursement, what do they need to do before and during that process?
AS: The litigation process, while I love doing it, I know my clients don't. So, what I want to make sure when I'm speaking with a client--that's why I mentioned that initial process from day one; it actually builds you up to have a successful litigation case. If you don't have the right benefit, and if you are not submitting a claim correctly, and you're not timely in following up on those denials, even before you come to me to file a lawsuit, I may have to tell you what nobody wants to tell you is that, "Hey, you don't have a case, you're going to lose because you didn't verify the benefit, or you didn't send in an appeal."
The litigation in this case tends to favor insurance companies. A lot of people, as attorneys, don't educate their clients enough about that process. But let's say you do steps A through Z and you're successful on that, and you come to me to litigate, I will tell you have a high chance of being successful against an insurance company. And here's the key to this: You don't see a lot of insurance opinions published because they never want to have a bad case on record. So, it's actually a lot quicker if you get all your ducks in a row and then approach an insurance company. You're likely to be successful in litigation.
TV: Any other mistakes that you see clients making that ultimately lead you to have to deliver bad news to them that they might not have a case? You outlined a few there, are there any others to keep an eye out for?
AS: The biggest two things that I see are medical record documentation, and then secondly, the timeliness of following up in exhausting administrative remedies. On the medical record documentation side, insurance companies will say, "Well, if the service wasn't there, it didn't happen." And it's hard for me as your attorney to provide evidence to that effect because there's nothing in paper. So that's always a really, really a big thing to keep an eye on. And as an organization, you need to have someone who's constantly auditing records and checking them.
The other issue with, hey, are we following up on timely denials and things like that. Again, it's just making sure that process to audit is there and those things are happening timely. So those are the two big things I always recommend. I can't stress enough the that the larger the organization is, bring in more resources to help you check those. This is your money at the end of the day. Without getting paid, none of the other pieces of this puzzle work. So, the last thing we want is to have a situation where you're not getting paid. This is really something I always emphasize to providers to educate them on. Learn the process, learn the requirements, and put those key people in place to make sure that the machine is working well.
TV: That certainly makes sense. Now you mentioned that insurers don't necessarily want to have cases on the record. Can you share any examples of recent cases that might be relevant to providers either positive or negative outcomes?
AS: Yes. What I will tell you is I have personal experience on positive cases, and most of mine that were positive are not published opinions because we ended up settling out of court. I'll tell you the two main things we're seeing: where there is a claim issue, meaning that the insurance company is not processing claims correctly, or they're not processing medical records correctly, they're going into limbo when it's not being done. And the reason we were successful in those cases against the very large insurers is I was able to show them the day it was mailed, the number of pages that were sent, how many pages they saw in their system. And they all sat there kind of like, "Hey, how did we miss 200 pages? Yeah, we can't really fight this. They did it. They can prove they did it right." Those cases have been very successful.
On the negative side, what we have been seeing is a lot of attacks on benefits themselves and medical necessity. There are some recent opinions where decisions about an insurance company's rights, or being able to say what they want or are considered medically necessity are kind of gaining some traction. The other big thing I will tell you right now, which is not necessarily a case, but it's new law: the No Surprises Billing Act. Any healthcare provider should familiarize themselves with this statute, and if they fall under it. It basically states that—and this is a very crude summary—if you're an out-of-network provider, you cannot balance bill or surprise a patient with a bill. So, a lot of the things that you may say I want to get money on or try to get funding from patients on, you're actually now not allowed to. It's really important to follow that statute and learn that. It really has impacted the way that a lot of my providers do business.
TV: All right. Amelia Shaheed, you have packed in a lot of information in a very short amount of time. Thank you so much. This has been great.
AS: Thank you so much for having me.
TV: As a reminder, you can subscribe to the BHE podcast on Apple podcasts and other podcast listening platforms. All past episodes are also available on our website, behavioral.net. Our thanks once again, to Amelia Shaheed, partner with the law offices of Julie W. Allison. I'm Tom Valentino, and this has been the Behavioral Healthcare Executive Podcast.
Reference
Shaheed A. Avoiding reimbursement claim denials and your legal rights as a provider. Presented at: East Coast Symposium on Addictive Disorders. Aug. 19-21, 2022. Baltimore, Maryland.
