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Addressing Problem Payers at Your Medical Practice


Have a problem payer at your medical practice? Here's how to identify and rectify the situation to avoid losing money.

When you sit down with your data at the end of the month and notice that there is one payer that consistently does not either pay correctly or on time, what is your recourse or approach to remedying this situation from occurring again?

Your first task is to gather more information. Go back a year or so and create a spreadsheet with pertinent information such as the patient name, the date they were seen, the codes you charged, what the insurance paid, the allowed amount, the date the insurance paid, if the patient had a portion to pay (co-insurance, co-pay, deductible) the contractual adjustment, and if there is a remaining balance. Do this for at least a dozen patients. This will create a visual map for you to review.

You are basically looking for trends. I know with the integration of ICD-10 and HIPAA 5010, I have seen very specific dates of service get completely dropped and no claims were sent out at all. A good billing company or department is looking for this particular trend, and should be able to identify this quickly and efficiently.

When you look at the codes that you have charged, are you certain that particular payer pays for those codes you've used? If you have created a Master Paid CPT report by payer identification number, this should be very easy to look up. You can also review the EOBs that are mailed to your office to identify if a particular code is consistently being denied or not covered for whatever reason (not a covered benefit, authorization not obtained, pre-certification was required, etc.).

Do you have a copy of your contract agreements with each of the payers you accept in your practice? This is critical to obtain if you do not. If you are unaware of how much you are supposed to be paid, and have it in writing, how can you hold the payer accountable for incorrect payments?

It is also worth pointing out at this time that many plans are starting to (if they do not already) cascade their payments. It is critical to remember to bill your most expensive code first, and the least expensive, last. For example, let's say you have four codes to bill for an office visit or procedure and the insurance is Blue Shield. Many of their plans, if not all at this point, cascade using the following formula: First code is paid at 100 percent, second code is paid at 85 percent, and the third and fourth codes are paid at 40 percent of your contracted rates. This is why it is so important to place your most expensive code as the first code to bill out. Many clinicians leave this administrative task to their back office manager or billing company. Be certain they are aware of which plans cascade and that the codes are being sent out in the correct order.

Next you can look at the date the insurance has paid. Do you notice if you are being paid consistently and on-time? If you are used to getting those Medicare payments in every two weeks, but now notice that it is taking more than three weeks to four weeks for these payments to arrive, you will need to investigate further as to the delay. Are you using modifiers correctly? Is there a yearly cap on a particular treatment? Educating yourself on these caveats will save you time and money.

Does the patient pay a portion of the visit via co-insurance, copay, or deductible? If you are not collecting this up front and instead choose to bill the patient, chances are your A/R will age out with this balance. If you have a contract with Blue Cross for say $85 for CPT Code XYZ, and the patient has a $40 copay, you will only be paid $45 from the insurance company. This is why collecting that co-pay up front is so critical.

Once you have reviewed these areas, you will get a really good idea where you need to focus your efforts to resolve the problem payer issue. Your billing company or department can assist you with this type of analysis very easily.

Next week, we will be looking at how to best train and inform your staff in obtaining correct authorization and pre-certifications with your payers.

Find out more about P.J. Cloud-Moulds and our other Practice Notes bloggers.

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