Sneaky Exclusions
by AJ Riviezzo and Cheryl Nash
We have seen a growing use of ‘riders’ for self funded plans. To help keep premium costs low, these self funded plans have carved a number of niches or riders out of the normal plan. We have seen a growing number of these riders being focused on varicose vein treatments. In short with these riders, the patient has no coverage or may have very different benefits.
The difficulty is that the administering plan’s front line people are unaware of these riders and frequently give incorrect benefit information. While you can sometimes use a complaint about incorrect information to eventually get paid, it is, at best, a gamble that takes up to a year to pay off.
If you are working with payers that typically administer self funded plans who may have a rider (CIGNA, Multiplan, some Blues plans), you may want to verify a little bit more. Ask the clerk if this is a 3rd party administered plan and if there are any exclusions. You may want to go ahead and have the claim reviewed by the pre-determination folks for that payer to ensure payment. We realize these extra steps take time and effort, but it is much better than giving care away unintentionally.
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