Every medical practice has had a bad experience with a payer. We asked physicians and providers alike to share their worst encounters.
Source:
Physicians Practice
Comments
We have many of the same issues listed here -- credentialing is one of them. However, this one takes the cake ...... Aetna is doing retroactive reviews.... from 2015. The most recent is that they now want to recoup all payments for a certain patient because her employer " did not have more than 100 employees and Medicare should have been primary." The claims paid without a copay, so although she had Medicare as a secondary, there was nothing to bill. Medicare says that we have passed the timely filing deadline for these particular claims and they will deny.
In another case, Aetna has determined that a patient's insurance was terminated half way through 2015 and several claims should have been denied. They of course want to recoup from us. This patient is no longer served in our office. Even if she had other insurance, it's long past timely.
If an error is this old, I think insurance companies should be required to seek repayment from the patient, not from the practice.
This is an update to an earlier post I had made. It is now 7 months since our nightmare started where two of my physicians were considered non-par because they did not show as "recredentialled" in the ins system. Since then after going through all parties available I finally sent a letter to the CEO- and as you can see I am still dealing with this. Because "their system" does not have the capability to do things "timely" this company has taken back monies paid on these physicians not once but twice(yep twice). Then has the nerve to ask for another refund. There should be a central organization set up for complaints such as ours to go to where insurance companies have to respond quickly and not use this "it takes time" response. Why is the government not overseeing them more stringently?
This is an update to an earlier post I had made. It is now 7 months since our nightmare started where two of my physicians were considered non-par because they did not show as "recredentialled" in the ins system. Since then after going through all parties available I finally sent a letter to the CEO- and as you can see I am still dealing with this. Because "their system" does not have the capability to do things "timely" this company has taken back monies paid on these physicians not once but twice(yep twice). Then has the nerve to ask for another refund. There should be a central organization set up for complaints such as ours to go to where insurance companies have to respond quickly and not use this "it takes time" response. Why is the government not overseeing them more stringently?
It's hard to say which experience is the "worst" but he's a recent one that has us currently steaming: This month a major payer in our community finally reprocessed well exams from 2015 where they had erroneously (and illegally) bundled the vision exam at all well-child exams. While it's great that we're now getting the money we are owed for this service, what's not great is that they payer, for about half the 2015 claims that were reprocessed, pushed the charges onto a co pay. When we asked the payer why they pushed a preventable service (by law in the ACA) onto the co pay, they couldn't/wouldn't give us a straight answer. There were some families where one sibling owed the co pay and another did not! Makes no sense and it's left us with a paperwork and patient-relations nightmare!
Although there were many reasons why my solo MD and I joined PNHP, payer frustration is a BIG one. Let's stop wasting hundreds of billions of dollars each year on insurance administration and adopt single payer. (http://www.pnhp.org/)
I am a Physician Practice Manager and share the frustration of these loyal and dedicated Physicians below that have responded. Physicians are forced to participate in unrealistic "incentive" programs outlined by CMS or lose a large portion of their reimbursement for the next year. It makes one wonder, what parties are making the decisions in Washington for healthcare? It is obviously not anyone with a healthcare background. Initially, healthcare was forced in to Electronic Medical Record or face penalties. This was of course very costly to all clinics and clinicians and many chose the penalty over the exorbitant cost of the Electronic Medical Record implementation. This process led many physicians to retreat to a prospective hospital to not only employ the Doctor and staff, but to also bear the cost of the required programs. This simply led to MORE action by the government; in requiring the establishment of "quality" programs that would require data extraction and submission by a certified vendor, which of course costs MORE money. Commercial insurances then follow CMS standards and require the same "quality indicators" to be reported on for their insured patients. Failure to comply will lead to more reasons for reductions in reimbursement. However, when I research denied claims from one of our major carriers, the reply is often, "I am not sure WHY this got denied, but at this point, the claim will not be paid. Please try again in 30 days." Of course this falls outside the 60 day time frame required for claims processing and they can again deny the payment. Until Insurance companies are held to a standard of timely claims processing and payment, why should the medical practice be penalized for not happily complying with their "quality incentive" programs? I am truly convinced that Healthcare is owned by Insurance, and whether you play nice in their sandbox or not, they will always create new reasons to reduce or deny your payments/reimbusement. Connie
And it's not getting any better is it?
Due to greed and incompetence we in the physician practice business have given it all away to government bureaucrats, insurance executives and lawyers. We have allowed a profession that once was autonomous, prestigious and had a good income degrade into wage-earner status as hospitals control more and more once independent physicians. Government now basically simply tells us what we'll do and how they'll pay us, and they can jerk back the leash at will with audits, denials and even bounty hunters!
So, we feel the only solution is early retirement. The chaos produced by Obamacare will only become worse and insurance companies will become more and more ravenous as they too are threatened by Obamacare. We're done. Goodbye
I keep seeing the alternative chosen being not improving the system by advances in quality, productivity, outcomes and best use of resources, but rather early retirement-- most any other profession does not have such an easy out-- and working till our SS retirement age and beyond is all we have. That and putting up with the same frustrations of life and the workplace that are just part of a job.
Healthcare needs leaders... leaders in improving the "healing arts" for the benefit of the population and not ones whose primary concern is wages and if someone might question their choices of care. Our healthcare expenditures approach 20% of GNP and our outcomes are close to those in the third world. Maybe some review of where we have been, where we are, and where we need to go is a good thing.
I can't access the rest of the pages. Stuck on page one.
I agree. The insurance companies have controlled this for too long. Physicians have been warned about "collaborating" to shut out carriers...well I think it is time physician practices get together to establish our own guidelines. We should have the right to place penalties in our contracts and enforce them. Contract negotiations are no longer a negotiation. The insurance tells you what they will pay and you can either accept it or lose that patient base. In Louisiana the new trend towards "Self funded" removes the State Insurance Commissioner and replaces it with Federal Labor Law. Not worth the red tape to fight incorrect reimbursement and medical decisions. My list is so long...
amen. Its gone downhill rapidly in the last 3 years (have been in solo practice for 15 yrs). FPs are dropping like flies. Some even opting for short term (3 year) contracts with local hospitals/ monopolies where its all based on seeing 40-50 pts a day or getting let go at the end of the contract. Schools seem to be popping up everywhere to try to educate enough PAs and NPs to take over for all the FPs that will be gone in the next 2-4 years. Concierge medicine is making a strong showing in NC due to all the fluctuation in payment and different plans that have complicated HSA/HRA/Coinsurances/ Deductibles and copays that need researched for every test and every visit.
When our company renegotiatied a fee schedule, the new one had to be "loaded" in their system before its effective date. The load was delayed over a month and when done, two of my docs were not loaded and claims are being processed as out of network. Trying to get someone on the phone to help with this is like walking through a maze. There error but our office is paying dearly. There should be penalties for them when something like this happens.
I have the same issue with United Healthcare. e had a tax id change for 5 of my clinics. They have my family practice providers set up as cardiologists, radiologists, home health departments. Have not had payment on claims for these providers since 1/1/2015. All you get is "it takes time to update the system".
Now with new plans being implemented I receive calls from UHC asking if a provider is contracted. A patient wants them to be their PCP but not on website. My response to them is " fix my contracting and your website and you can answer your own questions".
Why do organizations feel business works better when each person employed does 1 thing then hands it to the next person to do their thing? No one takes responsibility for it to be completed. All areas insist they did their part and it's someone else's fault.
Whatever happened to a representative being responsible for a practice. They load their demographics, their contract, their fee schedule and you know who to talk to if any issues. Now you are shooting in a barrel. Frustrated.
I'm on a current revolt in Arizona over the gross and unnecessary LONG delays in credentialing and "loading" contracts for new physicians. And even then they fail to get their data correct resulting in denied claims that almost NEVER process correctly for adjudication. We are seeing 6-9 months after credentialing starts to be issued an effective date. This seriously impedes a physician's ability to make a living, denies patients access to their services, and increases the costs in RCM immeasurably. If a physician has a medical license, DEA and malpractice it is reasonable to consider them thoroughly vetted and establishes a baseline for timely contracting. We are never denied a contract as we are a group and Arizona has a desperate physician deficiency. I am collecting my army and we'll storm the capital with pitchforks if need to change this obscene standard the insurance companies are controlling.
I am glad to hear somebody is doing something against the abuse, stress and unnecessary pressure doctors are facing everyday.
I have the same issue in Iowa. New providers can only see Medicare and Wellmark BCBS because the other insurance companies take 90-180 days for credentialing and contracting.
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We have many of the same issues listed here -- credentialing is one of them. However, this one takes the cake ...... Aetna is doing retroactive reviews.... from 2015. The most recent is that they now want to recoup all payments for a certain patient because her employer " did not have more than 100 employees and Medicare should have been primary." The claims paid without a copay, so although she had Medicare as a secondary, there was nothing to bill. Medicare says that we have passed the timely filing deadline for these particular claims and they will deny.
In another case, Aetna has determined that a patient's insurance was terminated half way through 2015 and several claims should have been denied. They of course want to recoup from us. This patient is no longer served in our office. Even if she had other insurance, it's long past timely.
If an error is this old, I think insurance companies should be required to seek repayment from the patient, not from the practice.
This is an update to an earlier post I had made. It is now 7 months since our nightmare started where two of my physicians were considered non-par because they did not show as "recredentialled" in the ins system. Since then after going through all parties available I finally sent a letter to the CEO- and as you can see I am still dealing with this. Because "their system" does not have the capability to do things "timely" this company has taken back monies paid on these physicians not once but twice(yep twice). Then has the nerve to ask for another refund. There should be a central organization set up for complaints such as ours to go to where insurance companies have to respond quickly and not use this "it takes time" response. Why is the government not overseeing them more stringently?
This is an update to an earlier post I had made. It is now 7 months since our nightmare started where two of my physicians were considered non-par because they did not show as "recredentialled" in the ins system. Since then after going through all parties available I finally sent a letter to the CEO- and as you can see I am still dealing with this. Because "their system" does not have the capability to do things "timely" this company has taken back monies paid on these physicians not once but twice(yep twice). Then has the nerve to ask for another refund. There should be a central organization set up for complaints such as ours to go to where insurance companies have to respond quickly and not use this "it takes time" response. Why is the government not overseeing them more stringently?
It's hard to say which experience is the "worst" but he's a recent one that has us currently steaming: This month a major payer in our community finally reprocessed well exams from 2015 where they had erroneously (and illegally) bundled the vision exam at all well-child exams. While it's great that we're now getting the money we are owed for this service, what's not great is that they payer, for about half the 2015 claims that were reprocessed, pushed the charges onto a co pay. When we asked the payer why they pushed a preventable service (by law in the ACA) onto the co pay, they couldn't/wouldn't give us a straight answer. There were some families where one sibling owed the co pay and another did not! Makes no sense and it's left us with a paperwork and patient-relations nightmare!
Although there were many reasons why my solo MD and I joined PNHP, payer frustration is a BIG one. Let's stop wasting hundreds of billions of dollars each year on insurance administration and adopt single payer. (http://www.pnhp.org/)
I am a Physician Practice Manager and share the frustration of these loyal and dedicated Physicians below that have responded. Physicians are forced to participate in unrealistic "incentive" programs outlined by CMS or lose a large portion of their reimbursement for the next year. It makes one wonder, what parties are making the decisions in Washington for healthcare? It is obviously not anyone with a healthcare background. Initially, healthcare was forced in to Electronic Medical Record or face penalties. This was of course very costly to all clinics and clinicians and many chose the penalty over the exorbitant cost of the Electronic Medical Record implementation. This process led many physicians to retreat to a prospective hospital to not only employ the Doctor and staff, but to also bear the cost of the required programs. This simply led to MORE action by the government; in requiring the establishment of "quality" programs that would require data extraction and submission by a certified vendor, which of course costs MORE money. Commercial insurances then follow CMS standards and require the same "quality indicators" to be reported on for their insured patients. Failure to comply will lead to more reasons for reductions in reimbursement. However, when I research denied claims from one of our major carriers, the reply is often, "I am not sure WHY this got denied, but at this point, the claim will not be paid. Please try again in 30 days." Of course this falls outside the 60 day time frame required for claims processing and they can again deny the payment. Until Insurance companies are held to a standard of timely claims processing and payment, why should the medical practice be penalized for not happily complying with their "quality incentive" programs? I am truly convinced that Healthcare is owned by Insurance, and whether you play nice in their sandbox or not, they will always create new reasons to reduce or deny your payments/reimbusement. Connie
And it's not getting any better is it?
Due to greed and incompetence we in the physician practice business have given it all away to government bureaucrats, insurance executives and lawyers. We have allowed a profession that once was autonomous, prestigious and had a good income degrade into wage-earner status as hospitals control more and more once independent physicians. Government now basically simply tells us what we'll do and how they'll pay us, and they can jerk back the leash at will with audits, denials and even bounty hunters!
So, we feel the only solution is early retirement. The chaos produced by Obamacare will only become worse and insurance companies will become more and more ravenous as they too are threatened by Obamacare. We're done. Goodbye
I keep seeing the alternative chosen being not improving the system by advances in quality, productivity, outcomes and best use of resources, but rather early retirement-- most any other profession does not have such an easy out-- and working till our SS retirement age and beyond is all we have. That and putting up with the same frustrations of life and the workplace that are just part of a job.
Healthcare needs leaders... leaders in improving the "healing arts" for the benefit of the population and not ones whose primary concern is wages and if someone might question their choices of care. Our healthcare expenditures approach 20% of GNP and our outcomes are close to those in the third world. Maybe some review of where we have been, where we are, and where we need to go is a good thing.
I can't access the rest of the pages. Stuck on page one.
I agree. The insurance companies have controlled this for too long. Physicians have been warned about "collaborating" to shut out carriers...well I think it is time physician practices get together to establish our own guidelines. We should have the right to place penalties in our contracts and enforce them. Contract negotiations are no longer a negotiation. The insurance tells you what they will pay and you can either accept it or lose that patient base. In Louisiana the new trend towards "Self funded" removes the State Insurance Commissioner and replaces it with Federal Labor Law. Not worth the red tape to fight incorrect reimbursement and medical decisions. My list is so long...
amen. Its gone downhill rapidly in the last 3 years (have been in solo practice for 15 yrs). FPs are dropping like flies. Some even opting for short term (3 year) contracts with local hospitals/ monopolies where its all based on seeing 40-50 pts a day or getting let go at the end of the contract. Schools seem to be popping up everywhere to try to educate enough PAs and NPs to take over for all the FPs that will be gone in the next 2-4 years. Concierge medicine is making a strong showing in NC due to all the fluctuation in payment and different plans that have complicated HSA/HRA/Coinsurances/ Deductibles and copays that need researched for every test and every visit.
When our company renegotiatied a fee schedule, the new one had to be "loaded" in their system before its effective date. The load was delayed over a month and when done, two of my docs were not loaded and claims are being processed as out of network. Trying to get someone on the phone to help with this is like walking through a maze. There error but our office is paying dearly. There should be penalties for them when something like this happens.
I have the same issue with United Healthcare. e had a tax id change for 5 of my clinics. They have my family practice providers set up as cardiologists, radiologists, home health departments. Have not had payment on claims for these providers since 1/1/2015. All you get is "it takes time to update the system".
Now with new plans being implemented I receive calls from UHC asking if a provider is contracted. A patient wants them to be their PCP but not on website. My response to them is " fix my contracting and your website and you can answer your own questions".
Why do organizations feel business works better when each person employed does 1 thing then hands it to the next person to do their thing? No one takes responsibility for it to be completed. All areas insist they did their part and it's someone else's fault.
Whatever happened to a representative being responsible for a practice. They load their demographics, their contract, their fee schedule and you know who to talk to if any issues. Now you are shooting in a barrel. Frustrated.
I'm on a current revolt in Arizona over the gross and unnecessary LONG delays in credentialing and "loading" contracts for new physicians. And even then they fail to get their data correct resulting in denied claims that almost NEVER process correctly for adjudication. We are seeing 6-9 months after credentialing starts to be issued an effective date. This seriously impedes a physician's ability to make a living, denies patients access to their services, and increases the costs in RCM immeasurably. If a physician has a medical license, DEA and malpractice it is reasonable to consider them thoroughly vetted and establishes a baseline for timely contracting. We are never denied a contract as we are a group and Arizona has a desperate physician deficiency. I am collecting my army and we'll storm the capital with pitchforks if need to change this obscene standard the insurance companies are controlling.
I am glad to hear somebody is doing something against the abuse, stress and unnecessary pressure doctors are facing everyday.
I have the same issue in Iowa. New providers can only see Medicare and Wellmark BCBS because the other insurance companies take 90-180 days for credentialing and contracting.
Add new comment