Here is an illustration for providers in the NYS Early Intervention Program that clearly illustrates the selfish orientation of thinking that is driving decision making on a central level at the Bureau of Early Intervention.
Exactly two months and two days ago, the Bureau of Early Intervention instructed providers to "accept claim amounts proposed by the insurer as payment in full from the insurer for the claim which are lower than the State-established EIP rate." Although they explained that this would not impact payments from escrow in the short term, we explained that accepting these payments in this way would be problematic because of the long term intent of having providers accept payments directly from insurers.
TODAY we received a DIFFERENT set of instructions from the Bureau of Early Intervention that states:
The Department is aware that insurers or insurer clearinghouses (Multiplan, Omni Plan) have sent expedited agreements to EI providers in response to claims submitted for EI services. The expedited agreements asked providers to accept claim amounts proposed by the insurer as payment in full from the insurer for the claim, which is lower than the State-established EIP rate.
DFS has recently informed the Department that commercial insurance plans that are regulated by New York State should not be sending these agreements to providers who submit claims for EI services. The New York State Prompt Payment Law requires that claims be processed within 45 days or the insurer could incur a violation and payment of additional interest.
Providers should no longer be receiving expedited agreements from insurers that are regulated by New York State. In the event that a provider does receive an expedited agreement from an insurer that is regulated by New York State in the future, the provider should not sign the agreement. Providers can determine whether or not the insurance plan for a child is regulated by New York State by accessing the child’s home page in NYEIS and by selecting the insurance coverage option, and select view for the insurance company and policy information. If this information is not available in NYEIS, the provider should work with the child’s service coordinator to obtain this information. The service coordinator and/or the municipality are responsible to ensure that current insurance information for each child is updated in NYEIS or in KIDS.
So in other words, because the BEI crammed this system in at the 11th hour and never did any of the proper planning to enroll providers into networks, insurance companies are doing what they do by trying to get providers to sign expedited agreements which essentially helps the insurance control costs by clearing the claim and processing it as an 'out of network' situation. That gets them off the hook for making a payment at the contracted rate.
The evil part is that when we see the insurance companies asking providers to accept negotiated rates the BEI is all over it and telling providers to go ahead and sign up - never telling providers what the long term impacts of those actions will be.
But when BEI figured out that signing the paperwork means that the BEI will get less than what they are entitled to, look how quick they are to issue guidance telling providers NOT to sign the paperwork!
I understand that the complexity of this runs so deep that only medical billers might understand the full nuances of PPOs, negotiated payments for out of contract work, and similar posturing in insurance-provider relations. What providers need to walk away with is the knowledge that if it serves the BEI they will take care of themselves. If it is an issue that at the moment they don't think will matter to the BEI then providers are on their own.
This issue is prima facie evidence that they have no idea what they are doing over there. Any provider that places trust for something as important as billing in the hands of this system is foolish - and we are all forced into a foolish situation because of the heavy handed way that the contracting came down and the absolute lack of meaningful stakeholder participation in making these transitions.
We would have all been better off billing the insurance companies ourselves and having the balances waterfall down to the escrow account as the payer of last resort. That would have been a tough potato for the provider community to swallow, but I absolutely promise that it would have left this system in a much more favorable position than where it is today.
In the meantime expect more guidance from the early intervention program as they "learn" about medical billing. It is all happening on your backs, but they understand that you are not organized and you have no powerful voices so they can get away with just about anything.