Filing a Complaint Against Your Payer

November 3, 2010

What can you do if your payer won't reimburse your practice for cleanly submitted claims?

It's a familiar scenario. Your billers are telling you that a payer hasn't paid certain claims even though the claims were submitted cleanly. The denials for certain services are piling up higher and higher. And you just received a letter from your largest payer stating that a fee cut will be going into effect 120 days from today.

What can you do to fight back? In some cases, there is not much you can do. Your contract with any given payer stipulates that it makes the policies and by signing the contract you agree to abide by those policies, even though they are likely to change as soon as you sign.

However, you should always complain to the payer if you disagree with a policy change. Why? Because if you don't, your silence equals acceptance. I have seen payers overturn their policy changes when sufficient numbers of network providers complained about the change. In some cases, policies are changed without the payer understanding the impact on its network. Feedback from providers is therefore very important in getting harmful policy changes overturned, or at the least, putting payers on notice that frequent changes are no longer going uncontested.

Where to start?

So how do you file a complaint with a payer? If you don't have an assigned representative, don't waste your time trying to track one down. Instead, go directly to the medical director at the plan. How do you find one of those? The simplest way is to Google the payer's name to bring up its corporate Web site. Call the main phone number and ask who the medical director assigned to your region is, and for her contact information. In nearly every case you will reach a live person, and they will usually provide you with the information you need. If you can't get the information you need, send your complaint to the attention of the payer's CEO at the corporate address. It will make its way to the right person pretty quickly. Call, write a letter, or send an e-mail - however you file your complaint, just make sure to do it.

Timely processing

In other circumstances you have clear rights, particularly when it comes to claims being paid promptly. In just about every state, payers must pay clean claims in a timely manner or face fines from state regulators. Timely payment is anywhere from 15 days to 120 days, but averages 30 days to 45 days in most regions. (To see what the Prompt Pay rules are for your state, click here.)

If you haven't received payment from your payer by the time the payment window in your state expires, use your state’s process and file a complaint with that regulatory body. Why? Because it will help get you paid. Once a complaint against a payer is initiated, the state regulatory organization opens an inquiry with the payer. The payer has a short period of time in which to research, respond, and correctly pay the claim before a regulatory fine kicks in. Often, filing an inquiry is enough to prompt the payer to remediate the problem at the source, making recurrence unlikely.

Do your homework

Before you file a complaint, make sure to take the time for due diligence on your part. You don't want to complain and then find out the payer never received the claim, or had processed it properly according to its rules. So how should you proceed?

• First find out if the claim was received.

• Then determine if the denial or nonpayment is due to a policy change (you can look up policies on most major payers' Web sites).

• If it is (and you don't agree) then file your complaint directly with the insurance company.

• If it is not due to a policy change and the payer is just slow to pay, or has created a billing process problem, then file your complaint with the appropriate state regulatory organization promptly.

Susanne Madden, MBA, is founder and CEO of The Verden Group, a consulting and business intelligence firm that specializes in practice management, physician education, and healthcare policy. She can be reached at madden@theverdengroup.com or by visiting www.theverdengroup.com.