Doctors are not attorneys, nor are they administrators. The information attorneys find useful to help you recover from reluctant insurance companies and health plans is within your control, but you may not know how to gather it or present it forcefully without good legal advice. Working with attorneys can help your office maximize its reimbursement.
What you do now
Most offices know how to approach billing disputes with patients. There are the phone calls, the follow-up emails, and – if necessary, the referral to collections. Sometimes the amounts are written off. Regardless, there is a system and you know the process. And when you assign an account to collections, you are content to pay a percentage of recover for a certain amount of legwork. You are unlikely to have a contract with your collectors to bring a lawsuit for uncollected amounts, suing patients is unpalatable.
You don't have a system in place for the commercial payers. Most offices have administrators follow up with prompt payment deadlines and resubmission (and resubmission) of required additional paperwork, but how many of you have seen successful resolution by way of the internal appeals process?
What you need
Each office should have a system in place to pursue disputes with health plans and insurance companies. And because these companies have lawyers, you need to have lawyers too. You need to be able to gather the sort of information that will make a difference, and present it in a way that will get attention. This requires lawyers, because advocacy is our job. Most important, we can bring actions in arbitration or in the independent dispute resolution process (litigation too, if needed). This can be done in a way with little cost to your office. Don't underestimate the power of the legal system to get results.
The sort of information that lawyers find useful, you will find useful for other reasons. If you invest in the value of data, you will see results in a stronger, more profitable practice.
Track denial statistics by reason
Track your R&C payments in particular by CPT code, date of payment, amount, insurer or plan, whether you have a contract or not, and if you're dealing with an employer plan.
The following is a brief outline of denial issues that often arise in contracted relationships (preferred and otherwise). This is the case especially due to the fact the average office deals with countless products, and these products change yearly. Add to that the fact that the people on the other end of the phone are not often very knowledgeable or helpful.
• Wrong contracted rate
• Problems with forms:
• Incomplete/inaccurate demographic information
• Service covered by another plan/payer
• Medical reasons
• Uncovered service
• Prior authorization/referral required (get confirmation)
• Claim already included as part of bundled payment or managed care program
• Lack of medical necessity
• Late submission (not tolled for asserted lack of documentation)
• Payers have state-law imposed deadlines for responding to and/or denying claims
• Medicare and Medi-Cal have different rates
• There are often "good cause" exceptions for delay out of plan
• Emergency care
• Non-emergency care