Massachusetts therapist hit with a $28,000 bill from insurance company over retroactive claim denial

MassLive.com

May 07-- May 7--Meg Arnould said she always took pride in her meticulous record keeping for her therapy sessions.

Then the Easthampton therapist was hit with a letter from an insurance company demanding $28,000. The company, who had recently reviewed six years of Arnould's patient records, was issuing a retroactive claim denial.

"Imagine if someone you worked for six years ago showed up at your door today and said, 'I don't like the work you did six years ago' and then demanded that money back without a clear explanation," Arnould, 39, said Tuesday morning during the Joint Committee on Financial Services hearing.

Arnould shared her story as she and other clinicians called for lawmakers to approve legislation that would limit certain claim denials, commonly called "claw backs." Bills S.589 and H.1078, would require insurance companies to submit claim denials within 12 months and only if they give clinicians treating mental health and substance use disorder a written explanation.

While health care providers have to meet billing deadlines, insurance companies don't have any deadlines for auditing clinicians and demanding payment years later, said Sen. Cindy Friedman, an Arlington Democrat who introduced S.589. Some insurance companies have directed third-party companies to pursue the retroactive payments.

"This has a chilling effect on how healthcare providers practice, discouraging many from take insurance, ultimately impacting patients' access to service," she said.

Under the bill, an insurance company would be required to submit claim denials within a year of service and would have to give clinicians a chance to make fixes and provide additional documentation to get paid. Under the bill, a clinician would get 30 days to take corrective actions or submit additional documents to get payment.

The bill includes exceptions to account for fraudulently submitted claims, claims or services tied to legal action, services that violate MassHealth regulations and other problems.

Therapists in Massachusetts have seen an increase in recent years in the number of insurance companies issuing claim denials one, two or even five years after a date of service, said Erica Kirsners, co-chairwoman of SEIU Local 509's CliniciansUNITED executive committee. Kirsners, who was worked in the field for 35 years, said she hadn't heard of "claw backs" until less than a decade ago.

Arnould has been in the field for at least 13 years, and she didn't think it would happen to her.

"Documentation was always stressed to me, so I just always assumed that if you provided the services, patients were covered and you had documentation that you would be OK," she told MassLive. "It was not something I really worried about until it happened to me."

Arnould specializes in trauma, autism, substance abuse disorder and other issues. She juggles some 15 cases as a part-time marriage and family therapist, often driving from one patient's home to the next.

When the insurance company asked to review her records for the past six years, she said she submitted them. Two weeks ago, she received a letter stating she has 30 days to repay $28,000 from retroactive claim denials.

Arnould did get a retroactive claim letter two years ago, but it was overturned after she appealed. This claim denial, however, is for a much larger sum.

She retained a lawyer and is fighting the claim denial.

"This is an example of the type of arbitrary and capricious practices that insurance companies use to bully mental health providers who don't have the resources to protect themselves against armies of insurance company lawyers," she told legislators Tuesday morning.

The Joint Committee on Financial Services heard several other bills related to insurance companies and access to health care, including one to increase transparency about what providers are actually available in networks and one against surprise medical bills.

___

Visit MassLive.com, Springfield, Mass. at www.masslive.com

Distributed by Tribune Content Agency, LLC.