South Florida Hospital News
Tuesday February 25, 2020
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January 2020 - Volume 16 - Issue 7

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Case Study Shows DCMA Can Help Address Reimbursement Issues for Members

The Dade County Medical Association (DCMA) has used this forum in the past to implore our members to utilize our association to take action to defend against the inappropriate reimbursement practices of insurance companies. A recent success story with the Medicaid program highlights how effective we can be when working together.

This case study involves a local pediatrician who reached out to our organization for assistance. He was an in-network physician for one of the local Medicaid Managed Care carriers. He was experiencing recurring issues with denials for Well Visits and Vaccination Administration for his pediatric Medicaid beneficiaries. The issues dated back several months and he was unable to resolve the issue working through his contacts.
 
While the DCMA would like to take some credit for the outcome, the real credit goes to the Agency for Health Care Administration (AHCA) and their commitment to hold Medicaid Managed Care Carriers accountable. By utilizing AHCA’s complaint portal, the DCMA submitted documentation to AHCA who in turn routed the concern directly to the carrier. Within 72 hours the carrier had reached back out to DCMA staff and confirmed they were addressing the situation. A week later we received notification that the carrier identified over $38,000 in improper denials that were being reprocessed and sent to the physician.
 
This case study illustrates that physicians do not have to accept improper reimbursement from insurance carriers. The DCMA can assist in routing your concerns to the proper channels for resolution.
 
Furthermore, this study illustrates that AHCA is living up to their promise to hold insurance carriers accountable for the delivery of care to Medicaid Beneficiaries as long as physicians and the associations that represent them utilize the complaint portal they have established.

If you have reimbursement issues with any insurance carriers, please reach out to the DCMA so we can help. For more information please visit www.miamimed.com.

 
Fraser Cobbe is Executive Director of the Dade County Medical Association. For more information, contact the DCMA at (305) 324-8717.
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