Deal or No Deal: Getting Medical Payers to Pay

There is a popular TV show on a cooking channel where contestants compete for $10,000 by cooking amazing food with wacky ingredients picked by a humorous and somewhat sadistic network producer. I was watching one of my favorite episodes a few days ago and found some shocking similarities between the show and the health insurance environment.

Let me explain:

The show starts with four contestants who are well-educated and renowned chefs in the industry. They cook in high-end restaurants across the country. These people know how to cook and make the most of every ingredient. I compare this portion of the show to the educated and highly experienced billing, coding, and administrative staff you have within your practice. They can look at a set of denial codes and tell the whole story about a claim.

Next, contestants are required to make an appetizer from the ingredients available in the basket of doom. These can range from a variety of foodstuff, including: fish heads, blue cheese, grape jelly, and peanuts. They must make a five star restaurant appetizer for three well-know restaurateurs and judges. This area of the show reminds me of opening the mail and reviewing denials, or payer correspondence as it relates to the payers rules, or speaking with a customer service representative. Everything is contradictory and the chances of receiving payment for submitted claims can be very slim.

Once the contestants are done with making their high-end appetizers within the 20-minute time frame, they then submit their creations to the judges with their fingers crossed. This totally represents the billing staff holding their breath and submitting appeals in the very-short time frame allotted. They stand in front of the insurance companies proud to present their appeals and claims for judgment.

Unfortunately, only three of the four contestants emerge from the appetizer portion of the show, and move on to the main course. This process continues through the dessert round, where two contestants are left, and then finally on to the victor.

The whole process of elimination is reflective of small practices that struggle to survive in this healthcare climate; fighting with the rules and contradictory judgments from payers. It's terribly unfortunate that these insurance companies are yielding all of the power and are able to decide who gets paid and who does not, based upon their wacky set of guidelines and rules.

The best way for your practice to survive and become the victor is to read, read, read all correspondence you receive from your payers. If it doesn't make sense to you, call your provider-relations specialist and ask as many questions as you can. It can be quite exasperating, and confusing; which is why it is so important to always learn as much as you can. Insurance companies are constantly changing their rules and guidelines for payment. If you are not keeping up with those, you will lose out on monies due to your practice.

It's a good idea to get a head start now and log on to each of your payers' websites and download the provider manual. It will be a tedious task, but once done, you will have armed yourself with the knowledge required to move your practice forward.