Procedures for Handling Billing Disputes

 

When a provider disagrees with the denial of payment or a reduced payment a medical billing dispute exists and the following steps shall be taken:

 

The Provider contacts the MCO to inquire about the reimbursed amount or denial of a medical bill via; e-mail, fax, phone, mail.  It may be necessary to submit the inquiry, along with supporting documentation, in writing to the MCO.  The provider and the MCO should keep detailed notes for his/her records, including the name and phone number of the person to whom he/she spoke, fax confirmations, etc.

 

It may be necessary for the provider to request to speak to an MCO supervisor to resolve the issue or to escalate the issue to a grievance conference.  Most provider billing inquiries can be handled by the MCO on the phone.

 

The MCO shall acknowledge the inquiry (e-mail, fax, phone, mail) within four (4) calendar days of receipt, and shall resolve or initiate resolution of the inquiry within seven (7) calendar days of receipt per the MCO contract.

 

If the issue is not resolved with the MCO, the provider should be instructed on how to initiate a medical bill grievance conference with the MCO.  The conference may occur in person or via telephone, and shall occur within seven (7) calendar days from the request for the conference.  MCO’s must document details of all grievances conferences and the outcome.  

 

The MCO shall issue a decision, in writing, within seven (7) calendar days from the date of the conference.  The MCO’s determination letter shall be imaged into the injured workers claim.  Imaging documents in the claim will make it possible for BWC to research any subsequent provider complaint that may come into the Provider Contact Center and will provide documentation that the medical bill grievance was addressed.

 

Required Elements for “Bill Dispute Grievance Conference Decision.” letter.

·         Identification of the specific documentation reviewed at the conference such as the office notes or other documentation;

·         Date, time, place and persons who participated in the conference (MCO and Provider) and the method used for the conference (phone, face to face or email).

 

If the provider does not agree with the MCO’s decision, the provider may contact BWC’s Provider Contact Center at 1-800-ohiobwc, option 3-0 or via email at feedback.medical@bwc.state.oh.us to ask for BWC’s assistance in resolving the billing dispute.  It is the MCO’s responsibility to inform and provide this information to the provider.  The BWC Provider Contact Center will ask the provider to document the complaint, which will be researched and tracked.    It may be necessary for the BWC Provider Contact Center to consult other BWC departments such as, (but not limited to) Medical Policy, Voc Rehab Policy, Medical Director or Legal or for input in making a determination.

 

BWC’s provider contact center will refer the provider back to the MCO if the grievance conference has not been held.  If the MCO did not conduct a medical bill grievance conference or the documentation has not been imaged into the claim,  the provider’s request for a medical bill dispute shall be referred by BWC back to the MCO.  BWC will educate the provider on the process and the steps that are established to handle such inquires/requests/grievances.

 

BWC’s Provider Contact Center will coordinate a written response to the provider and the MCO and send the response to the IW’s claim file.  After BWC’s determination is rendered, no additional levels of review will be considered.

 

If at any point during the inquiry/dispute process the MCO or BWC determines that a payment correction is needed, the MCO shall correct or submit an adjustment to BWC within fourteen (14) calendar days of determination. If BWC has reviewed and made a determination to instruct the MCO to pay the provider, the MCO will notify the Provider Contact Center when the payment is released. .