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Wiki Zelis Choice adjustment

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daniellebailey2244@gmail.com

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Hello there AAPC fam!

I am in need of some help. I just recently had received some EOB's from an insurance carrier whose patient's we have seen for over 10 years with no changes in payment, to receiving $50 less a claim due to Zelis choice adjustment. I have seen this with other plans like Cigna, however, there wasn't a change in the payments we were receiving. Have any of you seen this? And did you appeal?
 
They are applying their own adjustment because they're saying it's out of network. I would call them and inform them that you are not accepting their adjustment, and they can pay or the patient can pay. If they balk, tell them to show you a signed contract, that you have signed within the last 2 years, and you'll reconsider.
 
As a claims handling compliance and appeal specialist it is important to note that these repricing companies will use various manipulative and intimidating statements to get you to agree to negotiating a claim so they get a percentage of the money they saved the insurance company from paying you for services you rendered. Don't let them mislead you that you will get paid faster as timely or prompt payment is already a compliance requirement. Keep in mind that these companies are not considered covered entities, and you have an obligation to meet HIPAA security requirements in sharing patient information. So one way you can have fun rather than frustration in your job is to respond to these repricing company vendor representatives when they call by asking and requiring them to answer the following question "what is your direct relationship with the patient?" Once they state there is none, then merely tell them that since they do not have a direct business relationship with the patient, it is clear you do not have the patient's authorization to speak with them. They hang up frustrated and you hang up smiling. Sometimes when I am in the right frame of mind, I have even more fun by interrogating them asking them what % they get paid on the amounts they negotiate and what specific service they rendered directly to the patient to qualify for receiving a portion of your payment. Then follow it up with the question of what their direct business relationship is with the patient . Those are some fun responses to consider that results in frustrating them and not you. I would also like to share that you are not required to accept any repricing schemes applied to your claims whether it is through an insurance company or their incentivized repricing vendor (ie Multiplan, Viant, Data Isight, etc) As the statement reflects above make them prove there is a signed agreement authorizing the discount if they try to apply it. Along with that consider utilizing your right to appeal, and address any false and misleading documented statements included on the EOB.
 
Well, interesting response, but they didn't call her to negotiate a discount; they just took money off the payment they sent. Hence SHE needs to call THEM.
 
Thank so much for your advice I did reach out to the company, and it looks like the office manager did sign an agreement in February of 2019 (which I am not sure why she did, as I am the coding and billing manager) she might have thought it was for our Cigna patient's. If it makes any difference it has our old billing company's information on it and we are now doing our own in house billing? I did reach out to the insurance carrier Healthcomp (through Anthem) asking if we had signed a contract back in 2019 why are we just starting to see these adjustments as of April this year (all other payments this year have been the same as they have for years, we didn't see this last year at all either) the only information they could give me was the have new rates and discounts and they would look into why Zelis has taken over payments recently. Can I appeal these claims with a sign contract on file within the last 2 years? And I know this sounds silly but was is the best way to appeal, I haven't had to one of these before so I am not sure if there an appeal letter format I should use. Sharon what are your thoughts? Thank you both for all the advicce
 
The only thing they stated on there was 60% of the allowed amount will be agreed to as the repriced amount on all claims received and repriced by zelis. The lady I spoke to said I can try and get out of the contract I am just nervous it is going to mess with payments we receive from some of our other insurance carriers.
 
So when I read their webpage, it said basically that for out-of-network claims, they hunt around for a network. So the contract, was that for their network? I would find out who it involves. I refuse to contract with third party networks, too much shenanigans.
 
I agree, I am not a fan of third party networks. The office manage signed this thinking it was for one of our other insurances that has been using zelis for a long time now. This is the first time this insurance has been including in on this. However, it doesn't not state any specific insurance on the contract. I was going to write of letter of appeal for this insurance. Do you have any references I could use to put together a good appeal letter. I am just looking to receive payment from this insurance company as we have for year. Thank you again for all your help
 
daniellebailey2244@gmail.com said:
I agree, I am not a fan of third party networks. The office manage signed this thinking it was for one of our other insurances that has been using zelis for a long time now. This is the first time this insurance has been including in on this. However, it doesn't not state any specific insurance on the contract. I was going to write of letter of appeal for this insurance. Do you have any references I could use to put together a good appeal letter. I am just looking to receive payment from this insurance company as we have for year. Thank you again for all your help
Click to expand...

I would keep it as short and simple as possible. At the top, centered, all caps, and bold, put REQUEST FOR REPRICING/REPROCESSING. Then after the opening identifying information, put this:

The claim was processed and allowed $$$$$ with a "Zelis Choice Adjustment" of $$$$$$, resulting in a payment of $$$$$. However, we have not contracted for a "Zelis Choice Adjustment" for XXXXXXX insurance company, rendering this adjustment unauthorized. Please see prior claims for this patient of MM/DD/YYYY (eob attached) for correct processing.

We are requesting that you immediately reprocess this claim without the unauthorized adjustment, and pay the claim correctly. Further, we are forbidding you from taking any further unauthorized adjustments on our claims.
 
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