Contracted Physicians of Insurance companies

Contracted Physicians of Insurance companies

Jim DeWees

2/14/2013

Hello All,


I am using my other email account (Windows Live Mail) to write this email.
I typically use Hotmail, and I have heard that for some reason the
paragraphs are not separated, and it all just runs together. Let me know if
this works better.

The reason for THIS email is to share with everyone an idea that I have to
try to combat some of this unjust audit actions that these contractors are
using to deny our claims, finding minor issues, which end up withholding the
payments for services and devices that have been rendered in a fair, honest
and ethical manner.


What I am trying to do is figure out now how to file a Freedom of
Information act with Anthem/ National Government Services, and get the
actual name of the medical professional who reviewed the claims, reviewed
the audit packet, and denied the claim. By law, Anthem/NGS MUST have a
physician or other trained medical professional (I have heard that they have
some RN's that also review claims), and we MUST have access to the names of
these people who have reviewed these charts, notes and prescriptions. When
these people review the information, and then make a decision about medical
necessity or the level of services that were rendered, they have become a
treating physician and therefore we have a right to know who else is
making medical decisions for the patients.

Is there anyone here who has filed any paperwork based on the freedom of
information? Does it require an attorney to get involved with this? Is
there a form or anything to fill out and submit? Any help with this would
be greatly appreciated.

We should ALL request the names of the physicians or nurses who are
reviewing the claims, and denying them. We then must file formal complaints
with the licensing agencies of these people. For example, if the physician
happens to live and practice in Wisconsin (which was the case I had a few
years back, when Anthem gave me the name of the physician, not realizing why
I really wanted his name), we can file a complaint with the Medical
Licensing Board in that state, and explain to this board that we believe
that this physician (or nurse) has denied medical services for a patient,
but the REAL treating physician and other healthcare providers have written
orders and prescriptions for this medical service. We feel that the reason
this physician would deny such services is due to a financial interest for
his employer, Anthem/ NGS (or whoever the contractor or employer is), and
this physician appears to have made decisions that would benefit him and the
insurance company financially.

I can only imagine what a panel of physicians would say when they realize
that a fellow physician, who has a license that was granted by this board,
is using his license to work for an insurance company that these panel
members are fighting against every single day to get paid for the medical
services that they are rendering as well. This poor physician is going to
be taking a lot of heat from this panel, and I am sure will end up losing
his/her license to practice again.

This is the threat that I used with my contractor, telling the supervisor
that I WILL get the name of this physician, and I will file a complaint
against him/her. I will do everything to make sure their license is revoked
so they can never do this again. I will go one by one after these
physicians who are employed by Anthem and other insurance companies.

She asked me to NOT do this, and to not take this action. She said that we
can work together and get my claims approved and make sure we get these
fixed. I told her that ALL I do is legal, and that I have ALL the paperwork
that is required, and there is NO way these should fail an audit, AND there
should come a point when they realize this and QUIT doing audits on my
claims, and delaying payments, and also making it uncertain about IF I am
going to get paid for my work.

She has called me 2-3 time per week for the past 3 weeks telling me exactly
where my claims are, and what process they are going through. Whenever a
claim is approved, she calls me to let me know. So far ALL of my claims
have passed the audits, and she has called to let me know. I do have her
attention for some reason. I honestly think that she is just trying to keep
me happy, or keep me from getting more angry about this, and following
through with my plans of going after these physicians, and holding them
personally accountable.

These physicians are hiding behind a big wall of bureaucrats and seem to
feel insulated and protected from any legal action for their denials of
legitimate claims.

We need to change this perception, and we must HOLD them accountable for
their actions, if they are unjust.

So, please let me know if anyone has experience with the Freedom of
Information Act, as I don't want to spend a ton of money talking to some
attorney to have him/her file this for me if this is something that I can
do. OR if someone on here is an attorney, or has a connection with one,
please let me know if you can help.

Once I figure this out, I will share with you what the experience is, and
how you can also do this. We can make a difference here, and we can
hopefully make a change in what is going on.

I feel that this sharing of the White Paper is a good start for the
legislative angle, but for the practical angle, holding these physicians who
work for the insurance contractors need to be held accountable to what they
are doing.


Thanks

Jim DeWees, CP