Premera recently posted a notification on their website that there was a small goof in their network thanks to an error caused by the Washington Health Benefit Exchange.
Unfortunately the goof accidentally terminated over 26,000 existing Premera members who were supposed to have coverage. Undoubtedly, some of these are your chiropractic patients if you practice in Washington State and the northern part of Oregon.
While Premera and WAHBE are certainly working to fix this error ASAP, here’s what to do in the meantime:
Avoiding the Mess
- Verify Patient Coverage Online – use the online benefits tool for faster verification. Sure the phone will work, but can you imagine the wait times with over 26,000 errors out there?
- Double Check the Determination – if the patient comes back as ineligible, don’t accept this as the gospel truth. Double check with the patient that they indeed have coverage. If they insist that they do (probably the case 99% of the time), you can have the patient fill out an online request form for coverage retroactive to January 1 at wahealthplanfinder.org/
- Have the Patient Call WAHBE (855-823-4633) – if #2 does not produce results or your patient is not tech savvy, give them the WAHBE number and let them call to verify coverage.
How to Handle the Mess Aftermath
Undoubtedly, some of the claims you’ve already filed were affected by this error. In a perfect world, the mistake will be fixed before the claims are processed. Here’s what to do when that doesn’t happen:
Step A: Doubt all Denials – if you get a denied claim back for the reason that the patient has “no coverage in effect”, don’t believe it. Follow the steps above and double check the patient’s eligibility.
Step B: Submit a Corrected Claim – Not surprisingly, the major thing lacking in Premera’s notice is what to do to actually get paid. Unless Premera produces a system-wide edit that avoids duplicate claim submission for these patients, simply sending the claim again will end up getting denied (again) – this time as a duplicate. Instead, send a corrected claim with the explanation that the patient was incorrectly terminated and to please reprocess this claim.
Step C: Watch for a Better Solution – Admittedly, step B is cumbersome. Premera could potentially fix the situation on its own by issuing checks for patients who were denied due to the termination error. But somehow I doubt they will do that. Perhaps they will come up with a better plan – check the Premera website for guidance.