Bottom Line

Your patient has been denied disability.  He is on the phone complaining that either your medical records department or DataFile Technologies never sent his medical records to the disability insurance company.  We have often found there is a miscommunication regarding who is responsible for payment, causing the necessary records to not be released. In the following FAQ, we will explore the intricacies of patient responsibility as it relates to disability claims.

Government disability and worker’s compensation entities are very different than private disability or worker’s compensation insurers.  For the sake of this document, we are speaking specifically in regards to the private insurance companies which offer short/long-term disability plans to patients or underwriters of worker’s compensation plans for corporations.  These plans are meant to supplement government-funded disability or worker’s compensation and serve a very valid and valuable purpose to millions of people across the United States.  For the sake of clarity, we will focus on a disability claim, though the issues discussed also apply to situations related to worker’s compensation claims.

What is Happening?

A customer of a private disability insurance company is injured and unable to work.  The patient (customer) then submits a claim to his insurance company seeking disability payments.  If medical records are required for processing the claim, the insurance company will send a request to the healthcare organization, in this case a client of DataFile Technologies.  The information being sought can be anything from disability forms to standard medical records.  In some circumstances, the requestor will fail to either recognize or communicate which type of documentation is needed – possibly leading to a chaotic situation.  When a compliant request is received, DataFile Technologies will execute our workflow to retrieve the record and will send a bill (in accordance with state guidelines) to cover the retrieval cost incurred.

Reading the Fine Print

The next step in the process is often where communication breaks down.  Patients often do not read the fine print, which is known in the Release of Information industry as “patient responsibility.”  When an individual signs up with nearly any private disability insurance company, they sign a policy which includes language similar to “insured individual is responsible for covering all applicable costs for the retrieval of medical records to process a disability claim.”  The exact verbiage of this clause may vary, but the concept is standard across the industry.

Communication of patient responsibility for covering the cost of the retrieved medical records is the key.  However, like other situations in this industry, the standard practice can take two paths, or options, as described below.

The First Option

In some cases the insurance company pays DataFile Technologies for the medical records, then the insurance company pursues the cost of payment from the patient or they forward the invoice to the patient with educational material covering why a bill has been incurred.  All of this happens before any claim is processed.  As a best practice, all invoices sent by DataFile Technologies to disability insurance companies include the following language:

“If the patient is responsible to cover the cost for this copy of the medical record to be distributed to you, forward this invoice to your client and invite them to visit our website to make a secure payment.”

However, this option is not always a positive one.  If the insurance company does forward the invoice to the patient (customer), but does not receive payment for the retrieval of the medical records, then the claim may be denied on that basis alone.  If this is the case, then DataFile Technologies, or your practice, may be put in the position of trusting the insurance company to communicate effectively that this was the cause of the denial.

An important note here, insurance companies are not necessarily motivated to pursue collection efforts for the retrieval fee to be paid by patients.  Therefore, if the claim is denied due to lack of payment, your practice is frequently made out to be the scapegoat.  The only one who suffers in this situation is the patient.

The Second Option

This scenario is most likely to result in an upset patient reaching out to a healthcare organization.  In this scenario, communication from the private disability company to the patient is not present.  The insurance company receives an invoice from DataFile Technologies for the records which they have requested and replies with a very succinct letter expressing that the patient is responsible for paying for the records.  An example of such a letter includes the following language:

“We have received the enclosed correspondence [invoice] and are returning it for the following reasons: All payments are the Responsibility of the Patient.”  

“Please be advised that the enclosed medical bill will not be paid under the Disability Plan.  This plan does not provide coverage for medical bills or medical record copy fees.  Any such bills should be sent to the patient for consideration.”

At this point, the patient is unaware that their claims are not being processed.  The patient is unaware that charges are pending for the retrieval of their required medical records.  The patient is a customer of the disability insurance provider, therefore standard customer service logic would dictate that it is the responsibility of the insurance company to provide updates and needed information to the patient.  By corresponding only with DataFile Technologies, the insurance company is attempting to shift the onus for collection away from themselves while simultaneously inhibiting a claims process which might result in claims payment.  Once the timeframe for approval passes and the patient is subsequently denied their disability, the insurance company communicates to the patient that they never received the medical records needed from either the healthcare organization or DataFile Technologies.  This is results in an angry patient telling a healthcare organization that they (DataFile Technologies) are responsible for a denied disability claim.

While this situation is not rampant in the industry the scenario occurs often enough to create customer service issues for DataFile Technologies and healthcare organizations around the country.  It is the responsibility of disability insurance companies to share the necessary information and processes with their claimants.  We do not believe that it is your (or our) responsibility to organize the communication among patients and their private insurance carrier.  It is not that DataFile is unwilling.  There is a cost associated with this type of concierge service and most state fee structures for copies of medical records will not accommodate this.

Communication is Key

It is important that the team members at a healthcare organization understand the actions which ultimately may have resulted in a patient being denied their disability or worker’s compensations claim.  If the patient had examined their disability insurance policy close enough, been properly educated by the insurance company, or managed their claim more effectively, then the issue could have been avoided.  The ultimate point for consideration is whether a healthcare organization or their Business Associate (i.e. DataFile Technologies) has the capacity to manage the disability claim experience.

DataFile clients have the option to expand our traditional Release of Information services to include facilitating applicable patient payments for records related to private disability insurance companies.  If an organization is not currently outsourcing this type of workflow, then an option would be to educate staff on how to more thoroughly communicate with patients who may be seeking disability payments.  Leaders of these organizations need to ask themselves if they are obligated and possess the ability to manage issues not currently being addressed by many private insurers.

DataFile is committed to your patient’s satisfaction.  We encourage our clients to give us a call if they have any concerns regarding a patient being denied disability.  By taking the time to speak over the phone with our clients, we can work together to determine what caused the patient’s dissatisfaction.  If the denial is a result of a workflow lapse or oversight on our part, DataFile will work diligently to rectify the situation.