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Department of Managed Care Can Help Your Practice Get Paid


Know who you can turn to when you are continuously denied payment by an insurance company so that your practice can get paid all that it is due.

So, here I was smack dab in the middle of a dream. It was quite the dream, too! I had uncracked the code to the safe that holds millions of dollars of unpaid claims. As I opened the door to the safe, it all became very, very clear to me. Insurance companies who hold your money and make interest on it by delaying reimbursement should be sent to collections.

Yes, I said it. They need to go to collections just like any other person or business that refuses to pay their bills. Why should these publicly traded businesses be any different? They're not. We just have not figured out the correct combination to the safe - until now.

Although a collection agency for medical insurers does not yet exist (emphasis on yet), I do believe I can help you with some great tips to manage that outstanding A/R that you dread seeing roll over into the 120+ day category. Here are some things to consider:

• Know your denials by type. Do you know why you were denied? Was it because you went over an insurance visit limit, or authorization limit? If so, you will need to appeal these asking for retro-authorization or try to prove medical necessity with a prescription, chart notes, or anything that can prove the patient needed to be seen. Make a list of denials by type for all other denials that are not your fault (internal issues such as wrong policy number, cannot ID patient, etc.) so that you understand why the denial happened in the first place.

• Identify all unpaid dates of service where the insurance company has "dropped the claim." Re-bill those today.

• Know your contracts. This is so very important, and can feel like it would be a huge undertaking. But, you have to start somewhere, so:

1. Make a list of insurance companies you are contracted with, and locate those contracts;

2. Find out what the expiration date of each contract is, if there is one;

3. Find out what the timely filing limit is; and

4. Find out if the contract states how many days the insurer has to pay you.

That last one is really important, as some of the contract verbiage actually states that the insurer has to pay you interest on any unpaid claims, after a certain date. Did you know that? They're supposed to, but like "dropping a claim," they often forget to include that extra cash in your check. Why? You're too busy running a business or department to even notice.

Now that you have all of these areas covered and understand that the insurance company is still in the wrong - now's the time to take action. Get out a pen and write this down. Each state should have a department of managed care that deals with naughty insurance companies. They are the governing entity that helps you fight these greedy insurance companies into actually paying you what you deserve. You have to be certain that you have done everything correctly and that you are really due these missing payments. Once you find your states' agency, they'll have you sign up for an account, online. It's free and they will want your name, phone number, e-mail address, tax ID number, etc.; They will take your through a series of screens asking you to identify the insurance company, describe the problem, and provide specifics. Then you can follow the complaint through the system. The state will contact the insurance company on your behalf asking them why they have not paid.

The best part is you know have a partner in the industry that has a little weight to throw around.

The bottom line is: Make sure you send out clean claims as much as possible, and remember, when you are at your wits end with these insurance companies, know that you are not alone and that there is a hand outstretched to you ready to help.

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