Wiki GHI.... What's Going On Over There????? AR Issue

suki_26

Networker
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60
Location
Amityville, NY
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GHI has always been bad about processing claims. We joke that they have a denial wheel and every 4 - 6 months they spin it to see what code they will start denying across the board for no reason.
We are Out of network PCPs that have our own lab so we do not have a provider Rep that we can deal with. This makes it very difficult, especially since the pandemic started, getting ahold of a customer service rep is nearly impossible. 30 minutes on hold before getting a rep is the norm. Are there any other AR folks out there having this problem and have you found a way around it?

We have written letters to the corporate office to no avail. a corrected claim might be sent by mail and then unloaded to their portal AAAND still have to be faxed before we get a response. We have been trying to utilize the message center on the GHI website and we are getting the same reply regardless of what we send.....


"We reviewed our decision for claim number *********

The claim was processed correctly. No adjustments or additional payments will
be made.

If you have questions, call 800-624-2414 (TTY: 711). Our hours are 8 a.m. to 6
p.m., Monday to Friday. A Provider Service representative will be happy to
help.

Thank you for partnering with us to care for our members.

Sincerely,"


For this claim we sent a corrected claim and asked them to correct the diagnoses as it was a keying error. All paperwork and the corrected claim were uploaded directly to the inquiry. And the above was our reply. That doesn't even make sense!
Another example, even though Medicare crosses over their EOB's directly to GHI, we know GHI will say they don't have them so we automatically print them out and submit paper with a HCFA and mail it to GHI. We often have to send this multiple times and have even uploaded directly to their website. A lot of times it will still take a phone call where we are told they don't have the EOB so cant process. When forced the reps will "look deeper" and always find the EOB, send the claim to the "escalation dept", and it will eventually pay. Here is another Inquiry.......

Message Exchange
Reference Number: ********
Plan: GHI
NOT a duplicate. MCR originally processed and applied $18.66 towards coinsurance. medicare adjusted the claim and applied $25.93 towards coinsurance. MCR EOB's .attached. Please process for the difference which is $7.27
Reference Number: *********
Dear *********,

We reviewed our decision for claim number ********.
The claim was processed correctly. No adjustments or additional payments will
be made.

If you have questions, call 800-624-2414 (TTY: 711). Our hours are 8 a.m. to 6
p.m., Monday to Friday. A Provider Service representative will be happy to
help.

Thank you for partnering with us to care for our members.
Sincerely,
**************************************

Message Exchange
Reference Number: 05968523
Plan: GHI
Please see the attached corrected claim and adjusted Medicare EOB. kindly reprocess for Medicare coinsurance of $26.76. Thank you.

Reference Number: ********
Dear *********,

Thank you for being an EmblemHealth Partner.


In response to your email, please be advised that GHI follows primary carrier
rule and pay only the coinsurance amount issued by primary carrier, as there is
no coinsurance amount GHI processed claim for $0.00. Please contact the member
for deductible amount of $187.03 as patient's responsibility.

If you have questions, call 800-624-2414 (TTY: 711). Our hours are 8 a.m. to 6
p.m., Monday to Friday. A Provider Service representative will be happy to
help.

Sincerely,


We have considered the Insurance Commissioners office but as most of our GHI plans are NYC employee plans they fall under self funded and therefore not handled by the insurance commissioner.
If anyone has any tricks or tips at all we would be greatly appreciative.
 
I'm puzzled why you're going to these lengths for an out-of-network payer. It's good of you to do all this work for your patients, but if you're not in the network, you're not compensated for this and should be billing the patients. Let them pressure the insurance companies if they're not happy with the way their claims have been processed. I know NY has stringent balance billing laws - is that what is preventing your organization from holding the patient accountable?
 
I'm in agreement with Thomas. TPA's can write their own rules and take advantage of it. An upset patient on the phone is the best way to get their attention.
 
We are actually In Network With Medicare ( the only ins we are in network with) but OON with the GHI 2ndry

These GHI policies have OON benefits therefore it is there responsibility to pay. Its not the Patients responsibility. I would never send a patient a bill for something the insurance should be paying (unless of course the insurance company sent the check directly to the patient). Most of our patients are elderly and would have no idea how to fight with the insurance companies and if I pawned it off to them that would make me feel as lazy as GHI is being . As an AR specialist this is my job.
 
We are actually In Network With Medicare ( the only ins we are in network with) but OON with the GHI 2ndry

These GHI policies have OON benefits therefore it is there responsibility to pay. Its not the Patients responsibility. I would never send a patient a bill for something the insurance should be paying (unless of course the insurance company sent the check directly to the patient). Most of our patients are elderly and would have no idea how to fight with the insurance companies and if I pawned it off to them that would make me feel as lazy as GHI is being . As an AR specialist this is my job.
If your provider is out of network, then the patients are responsible for these balances if their secondary plan fails to pay, and it is possible to bill patients yet still be professional and respectful of their needs in the process. As an AR specialist, your job is to support your employer and their financial viability too. If this is the process your organization has chosen, then like I said, it's very generous and within their rights that they do that for their patients, but I imagine it's costing them.

If GHI is not responding to you and billing the patients is not an option, then for the dollar amounts you're talking about above, your organization may want to evaluate whether it may be more cost effective just writing these off vs. putting the staff hours into pursuing these balances - how to balance collections against patient satisfaction is the kind of business decision every practice has to make for itself. But if you're not in network, then you really don't have much leverage here. Maybe your organization should consider joining the network?
 
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I understand what your saying about the man hours it takes to pursue these claims. Unfortunately GHI likes to randomly pick a new code that was previously being paid and then across the board deny it. It may be only a few dollars here or there, but when you add up all the claims together its much more.

The above claim has to do with Medicare in the beginning of the pandemic telling us to all bill Place of service 2 and then they changed their minds. We had hundreds of claims to reprocess through Medicare and then unfortunately reprocess back to GHI. GHI denied pretty much all of them as duplicates even though we provided the appropriate documentation so there should have been no confusion.

It becomes very frustrating when this is all the time!! It could just be a NY GHI thing but its bad! I'm currently working on a project where they are denying code 85651 on over 50 patients for a specific date range that they previously paid on multiple times. It gets to the point of where do you draw the line. I honestly believe they do this randomly in the hopes that we will just write it off. This saves them money when we don't fight for it but I guess I just don't believe they should be allowed to get away with that.
 
I agree that Emblem (the parent company of GHI and HIP) seems to care very little about the providers, whether in or out of network (I've had experience with both). Even in network, you do not have any type of provider rep that you can actually speak with to resolve any issues.

If you are billing GHI only for 2ndary to Medicare, I will provide a couple of tips.
1) If the patient has GHI as a NYC employee or retiree, they do NOT cover the Medicare deductible (whether in network or out), and there is an additional $50 patient responsibility before GHI covers the co-insurance. For our GHI patients, at least 90% of them have the NYC employee plan.
2) I would also note you mention 85651. This is a lab code, and if the patient has Medicare primary, I don't believe there would be any co-insurance. There would be no balance for GHI to process.

If you are billing GHI primary out of network, as Thomas mentioned, the burden does fall on the patient for non-emergency services provided in your office. The balance billing and no surprise bill laws specifically pertain to patients who are receiving emergency services and other services where you cannot choose your provider (anesthesia, pathology, inpatient services, etc). If GHI is not paying, the patient is responsible. It might be prudent to make your patients aware prior to services that you are having issues with GHI and that you will submit one bill for the patient as a courtesy, and then beyond that, the patient is responsible.

Good luck!
 
Thank you everyone for all the replies.:)

I think when it comes to GHI "it is what it is" sadly.
They are getting clever... with the 85651 these patients have primary GHI and we are getting the denial of
" This procedure is not covered when billed by this provider specialty. This is a provider liability and member cannot be billed"
We are Internists/PCPs not specialists so they are covering themselves with the bogus denial.

We have even looked into going in Network but as with most commercial insurances they don't want to put our in house lab in network as well so it doesn't pay for us to do that.

I remember a time when GHI was much easier to deal with. You didn't have to wait long to get a rep and to get a claim reprocessed was much quicker. guess I'm showing my age that was a long time ago. lol

If I find a magic fix I will definitely share it will all. Right now the best I have is calling first thing in the morning and getting a rep. IF you can get a rep to internally Reprocess the claim you have the best chance of it going through correctly.
 
****** BUMP TO TOP *****
I'm bumping this back up to the top. in hopes ANYONE is dealing with the same thing here in NY and has any ideas.
GHI is no longer accepting providers to go in network ( so we are told)
I have spent a lot of time getting customer service to Reprocess my claims for this particular code 85651 . we just got 20 letters in the mail with THE EXACT SAME DENIAL on every single one... also the same denial comes back with any online inquiries..... " The claim was processed correctly"

I understand writing off small amounts here and there but on this project alone it would be $504. If we do this every time they decide to not pay something the amounts would be shocking!!

As these are self funded NYC employee accounts we can not even utilize the insurance commissioner.
We have written letters to any heads of departments we can find online and get no response.

Is our only recourse to no longer accept patients with GHI? Or are we forced to just accept whatever BS GHI dishes out and just eat it?????
 
One thing I've heard somewhat consistently about situations like this is to get the patient to complain to their insurance company about it. Not a guarantee that it'll go in your favor, but it might be possible rather than just writing it off or stop taking those patients.
 
Since you're out of network, I stand by my advise that the patient is responsible. I would advise the patient prior to the appointment. Have the patient pay for the service and inform them you will submit the bill to GHI as a courtesy showing the patient paid, but the patient must do any follow up.
For several years now, GHI won't accept providers unless they also agree to become participating with HIP and Emblem plans. I believe all the plans are currently paused for new providers unless they are joining an existing participating group.
 
On this particular project the end of the original denial is ..."This is a provider liability and member cannot be billed"

Having to contact all our GHI patients and have them fight for this , as it is possible, could be even less cost effective than my fighting directly with GHI.
(Insert confusion in trying to explain Surprise bill act to patients. )

I think I'm going to look into ERISA. Have you gone that route before?
 
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