There's absolutely no doubt that, as a physician, you have had personal experience with payer hijinks. Ask any doc; he's got plenty of examples. But bellyaching alone won't get your claims paid. It helps to have a clear, unbiased view of the types of payer red tape that cause the most troubles and to employ effective strategies to circumvent the worst payer traps.
Jane Siegel, an orthopedic hand surgeon, believes that most problems with payers are essentially universal across all practice types, but acknowledges these problems are heightened for smaller practices. She says her Nashville-based orthopedic practice, Tennessee Orthopedic Alliance, is better positioned than its smaller peers because of its size; it numbers 50 surgeons, and has an in-house billing department. But even it faces significant challenges when it comes to payers.
"So a big part of our central billing office is trying to figure out each insurance company — how they want you to bill for each procedure, will they consider bundling and kick back your claim? There's no uniformity, there's no way we can do one set of billing, one set of coding. [We have] to be specific to each insurance company," says Siegel.
If you'd like to get a better handle on your payer relationships, where do you start? Given the complexity of payer rules and insurance products, you might want to start with an overview of common payer hazards.
The types of difficulties that physicians and their practices experience with payers can be broken down in several broad categories, encompassing everything from contract negotiations to unannounced rule changes. Here are a few of the most troublesome hazards that plague practices and their billing staff:
David Doyle is CEO of revenue cycle management firm CRT Medical Systems, which has been in business for 33 years and works with both private and government payers; and since the beginning of 2014, the new healthcare insurance plans sold through federal and state exchanges. Doyle believes that it is too early yet to quantify the impact of these new insurance plans, and notes that it is difficult to tease out claims data belonging to them because they are generally sold by major payers. "… I don't know when I'm sending claims in to Aetna whether it came through an exchange or the employer."
Irrespective of any one insurer, Doyle says the biggest problem in working with payers is the inconsistency of payer rules. "There isn't any requirement by payers to adhere to a set of rules, in terms of how they approve or pay claims. So when you move to one payer or the next, those rules are different," says Doyle. He also says the rules can be different depending on medical specialty or region.
Another difficulty that practices commonly encounter, says Doyle, is inconsistent methodology for submitting claims. Despite the fact that most claims are now submitted electronically, many payers require additional companion documents to support the claim, adding to the complexity of the claims process.
LACK OF COMMUNICATION
Medical billing consultant P.J. Cloud-Moulds, owner of California-based Turnaround Medical A/R Recovery, likens working with payers to a "game" where she applies her knowledge and persistence against obscure payer tactics. She can, however, see the other side of the coin, noting, "I'm not one to side with the insurance company, but they have their limitations. Often, it's software that doesn't work properly, or they are spread really thin."
Perhaps that accounts for hours-long phone calls waiting for a payer representative to clear up a problem with a claim? But that wait is definitely worth it, as Cloud-Moulds doesn't trust the information posted on payer websites. She says it is often outdated or just incorrect.
And there are times when payers communicate patient information that is patently false: for instance, telling practices that a patient's insurance plan has been terminated, when it hasn't. "We call the patient and say, 'Hey, did you get new insurance?'" says Cloud-Moulds. When the patient invariably says no, she says the insurance company is very lackadaisical in its response, "Oh yeah, that was our mistake. Sorry."
Oftentimes payers will state that they never received a claim; not until you contact them to track it down. Doyle estimates that 10 percent to 20 percent of the claims CRT Medical Systems processes fall into that category.