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How to Get What Your Practice is Owed in Payer Reimbursements


If you are not tracking what you are being paid from your payers, how do you know you your medical practice is being paid correctly?

With the common knowledge of declining reimbursements, and healthcare executives raking in the money, do you trust this same group of individuals to pay you what you are due by contract?

Let's say that Insurance Company XYZ is supposed to pay you, by contract, $78.50 for CPT Code A and $63.20 for CPT Code B. You often use these two codes when seeing routine patients. That would be a total of $141.70 for that visit. Now let's say that they pay you $141.00 for this, instead. At 70 cents less payment per visit, and you are seeing approximately 7,560 per year, this would add up to $5,292 that you are being shorted by Insurance Company XYZ, just for these codes!

Is this legal for them to do? Of course it's not. Do they try to get away with it anyway, citing clerical error? Yes, every day. You'd never be able to pay a different amount to your mechanic or at a restaurant other than what is on a bill, so why allow your reimbursements be cut short?

What can you do to minimize this type of “clerical error?” You need to build yourself a rate sheet based upon contracted rates, and compare these, often, with what you are actually paid. This would be a great project for that individual in your office that tends to get their work done, and is looking for a challenge. They can work with your billing department to develop such a spreadsheet.

It might look something like this:

Some billing companies have a field built into their software that will flag an account when a different amount is posted than what is supposed to be. But for those who do not have this, it is a critical step to set up a quality control system of the payments coming in. 

What do you do when you find this happening to your reimbursements? Have your billing company appeal those incorrect dates of service. If the comment comes back to you, “It's not worth our cost to resubmit,” consider what the overall cost is to you and your private practice. Why should someone else be able to put a price in your business?

Something to consider, also, is that the more often you appeal these “mis-payments,” the more often the insurance companies will cut down on these mistakes. You will end up on their radar, so be ready for them to start auditing and asking for chart notes to support medical necessity. Yes, it is worth it.

So, take the time to pull your rates together, work with your billing department and make sure you are being paid what you are owed! You're worth it!

Next week, we will look at what criteria are necessary for “medical necessity” from an insurance company.

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

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