Save the Date! Fri., Jan. 3rd, 2025

RECAMFT's Golden Jubilee - In-Person at Odd Fellows Hall, Santa Rosa

50th Birthday Celebration! 

• In-person at Odd Fellows Hall, Santa Rosa
• Speaker, Annual Members Meeting, Awards, Prizes! 
• Lunch will be served

Join us and your colleagues for a Friday filled with fun enjoying the time together with friends, celebrating our wonderful community! Save the date!!

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A Lesson in Perseverance: The Long Saga of a Rate Increase Request (Part 1)

By Pat Hromalik, LMFT

President Elect Candidate, Current Director at Large, RECAMFT.org

I am a practitioner that takes insurance, as many of you do. And, of course, I share the frustration about the low reimbursement rates from many insurance companies. I am also a consumer of Barbara Griswold’s expertise and information on all things insurance related. (see Navigating the Insurance Maze https://theinsurancemaze.com). Early on I followed her advice in trying to seek rate increases on a regular basis from Beacon where I was contracted to offer services for Kaiser Commercial outsourced referrals.

I wrote a factual letter containing the average Master level rate of pay in the Bay Area, included research on the number of therapists in my area takings this type of insurance compared to the high demand, as well as my own credentials, including additional and specialized training. While the process was NOT speedy, I was successful in submitting and getting rate increases approved every 2 years. Their stated service levels are to receive an acknowledgement of the request in 30 to 45 days (yes, I know that sounds ridiculously slow), and to complete the process in 90 days. They met their service levels both times while they were still Beacon. I was able to submit my request via email to their provider relations email and was eventually acknowledged and then assigned to a contract specialist where we negotiated and finalized the increase. They also allowed reprocessing of claims back to the date of the signed new rate increase agreement.

Now here comes the Loooooong Saga…

November 1st 2023 I followed that same process described above, however Beacon was now operating as Carelon Behavioral Health. I heard nothing, and followed up by email, again with no response. I then called the Provider Relations Customer Service line and was told that email address was no longer being used (note there was no bounce back message when the emails were sent) and that contract rate increase requests were being taken over the phone. While that didn’t make sense to me, I followed along and gave the representative the CPT codes and my requested rates for each. They stated the same service levels I described above. I called back after 30 days and was informed the service level was business days not calendar days. I dutifully called back in 30 business days – and was told it was pending and could take 45 days. I called again in February 2024 (way after the 45 business days) and was told it was processing and they had no explanation for why an acknowledgement had not been received. I, of course, was doubting that the request has gone to the Contracts area. I called again and tried to get to talk with someone in contracts but was refused, as well as being unsuccessful in getting to speak with a supervisor. I also tried emailing to a new provider relations email advertised in one the Carelon’s monthly newsletter and again got no response. On April 19th 2024 I wrote a terse paper letter to Carelon regarding my experience to date along with copies of each correspondence (yes copies of all the emails, and each phone calls identification number and who I spoke with). I sent the letter certified. On April 25th 2024 I received an email from a contracts manager saying that my request was assigned to her and she needed me to fill out a form with the CPT and rate increases requested. I did that and returned it the same day, except that the rates I requested were higher than in November as I wanted the Kaiser rates to be on parity with the Medicare rates which had just been increased and announced. I heard nothing. In May and June I emailed this contracts person for follow up and got no response each time.

Now I’m really mad…

The feisty part of me boiled over in August! I was mad! I decided to try to find out who the CEO of Carelon was and write to them. I found the CEO and a VP of Quality and wrote a letter to both of them. I mostly needed to vent but a small part of me thought it might catch someone’s attention and I might get an apology and some action.

My prior careers were working in technology and management and leadership development for 3 different fortune 500 companies in insurance. So, I wrote from the perspective of providers being the service arm of their business, as well as from a quality perspective (I am 6 Sigma trained in quality process improvement). And guess what? I heard nothing!!!! To be fair I has trouble finding a corporate address and did find what I thought was the right address, but who knows if it really was where these two executives worked.

And then a miracle happened…

In early September, I was looking back over all the documentation I had from this frustrating experience and I noticed in very small print on one of the emails from the contract person there was a phone number. So, I called it. And left a message. A few days later I called again and miracle of miracles – the contract person answered – she had been out of the office! And she was an angel! At first she spouted the party line – ‘we are not processing any commercial rate increases until October.’ When I pushed and said this was a request going back to November of 2023 and she had the request since April, she paused and started to look in her documentation. She found it had been mislabeled as a Partnership Health Plan request instead of a Kaiser Northern Californian Commercial request. As she looked over the letter and documentation she apologized and said I had documented everything and she would work on this request and work on getting it back dated to 11/1/2024! She told me she needed to put it on one of their updated forms and would send the form to me which she did and I returned promptly. She was having some computer problems and set an expectation to have the information reviewed by the next week. Which she did and told me due to the amount I was asking for it would need to be approved by her manager but she was fairly certain it would be and set expectation it would take about 10 days. I followed up with her in mid-September right before I was to go out on a medical leave for surgery. She assured me that the request was sent for approval and was reassuring as well as very concerned about my surgery. We corresponded a few weeks after my surgery and she told me the rate request was approved. YEAH! She also said she could only back date 3 months and had put in a request to her manager to see if she could approve a longer back-date period. Her manager was out traveling and it could take a little time to hear back. That was October 10th.

So, I am cautiously optimistic. I know the rate increase is finally approved – almost a year later – but not sure how far back they will back date it. If they do what she is advocating it will be a miracle and will truly restore my faith that there are some high caliber, quality minded people at Carelon who understand the value of their providers and want to provide good service to us.

So stay tuned for Part 2 – the final result!!!

Pat Hromalik, LMFT, has a private practice in Petaluma, CA. She currently serves as a Director at Large, and is currently running for President Elect on RECAMFT's Board of Directors.  

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