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Keeping Up With Changing Payer Policies


Payer rules are complex and constantly change, making them difficult to follow. Here's what your medical practice should watch out for.

There's absolutely no doubt that, as a physician, you have had personal experience with payer hijinks. Ask any doc; he's got plenty of examples. But bellyaching alone won't get your claims paid. It helps to have a clear, unbiased view of the types of payer red tape that cause the most troubles and to employ effective strategies to circumvent the worst payer traps.

Jane Siegel, an orthopedic hand surgeon, believes that most problems with payers are essentially universal across all practice types, but acknowledges these problems are heightened for smaller practices. She says her Nashville-based orthopedic practice, Tennessee Orthopedic Alliance, is better positioned than its smaller peers because of its size; it numbers 50 surgeons, and has an in-house billing department. But even it faces significant challenges when it comes to payers.

"So a big part of our central billing office is trying to figure out each insurance company - how they want you to bill for each procedure, will they consider bundling and kick back your claim? There's no uniformity, there's no way we can do one set of billing, one set of coding. [We have] to be specific to each insurance company," says Siegel.

If you'd like to get a better handle on your payer relationships, where do you start? Given the complexity of payer rules and insurance products, you might want to start with an overview of common payer hazards.

The types of difficulties that physicians and their practices experience with payers can be broken down in several broad categories, encompassing everything from contract negotiations to unannounced rule changes. Here are a few of the most troublesome hazards that plague practices and their billing staff:


David Doyle is CEO of revenue cycle management firm CRT Medical Systems, which has been in business for 33 years and works with both private and government payers; and since the beginning of 2014, the new healthcare insurance plans sold through federal and state exchanges. Doyle believes that it is too early yet to quantify the impact of these new insurance plans, and notes that it is difficult to tease out claims data belonging to them because they are generally sold by major payers. "… I don't know when I'm sending claims in to Aetna whether it came through an exchange or the employer."

Irrespective of any one insurer, Doyle says the biggest problem in working with payers is the inconsistency of payer rules. "There isn't any requirement by payers to adhere to a set of rules, in terms of how they approve or pay claims. So when you move to one payer or the next, those rules are different," says Doyle. He also says the rules can be different depending on medical specialty or region.

Another difficulty that practices commonly encounter, says Doyle, is inconsistent methodology for submitting claims. Despite the fact that most claims are now submitted electronically, many payers require additional companion documents to support the claim, adding to the complexity of the claims process.


Medical billing consultant P.J. Cloud-Moulds, owner of California-based Turnaround Medical A/R Recovery, likens working with payers to a "game" where she applies her knowledge and persistence against obscure payer tactics. She can, however, see the other side of the coin, noting, "I'm not one to side with the insurance company, but they have their limitations. Often, it's software that doesn't work properly, or they are spread really thin."

Perhaps that accounts for hours-long phone calls waiting for a payer representative to clear up a problem with a claim? But that wait is definitely worth it, as Cloud-Moulds doesn't trust the information posted on payer websites. She says it is often outdated or just incorrect.

And there are times when payers communicate patient information that is patently false: for instance, telling practices that a patient's insurance plan has been terminated, when it hasn't. "We call the patient and say, 'Hey, did you get new insurance?'" says Cloud-Moulds. When the patient invariably says no, she says the insurance company is very lackadaisical in its response, "Oh yeah, that was our mistake. Sorry."

Oftentimes payers will state that they never received a claim; not until you contact them to track it down. Doyle estimates that 10 percent to 20 percent of the claims CRT Medical Systems processes fall into that category.


If you work with medical billing long enough you come to know how long the typical turnaround time should be for each payer. Doyle says his company knows that after they submit a claim, it "should have a response from Blue Cross Blue Shield in 10 days, Medicare in 14 days, and let's say Aetna in 30 [days]." That's why he says it's imperative for practices to put a process in place to flag outstanding claims - some practice management systems do have that capability. However you track your claims, Doyle says, "When you know [it is late] don't let a claim sit there and, so to speak, languish."

Cloud-Moulds says, "There are a lot of nasty payers out there that will automatically deny [a claim] on the first pass," or randomly skip individual claims that are batched and submitted electronically together. So it pays to do your homework, and track down all outstanding claims.


"I think the most common frustration for physician groups has to be network contracts," says Siegel, who is also a board member of the Tennessee Medical Association. "Contracts allow insurance companies or payers to arbitrarily change fee schedules [and] payment policies; they can make changes that directly affect reimbursement during the contract period with little or no warning."

She adds that unlike the recent past, negotiating with payers has now become largely a "take-it, or leave-it" proposition. Many payers, like Blue Cross Blue Shield of Tennessee, hold a huge market share in the states they do business in. "Blue Cross Blue Shield, which is huge, [I estimate] makes up 70 percent of [my practice's] payer mix. And so you really can't drop Blue Cross," Siegel says. And these mega-insurers often are involved in state managed-care programs as well, like TennCare (Medicaid) in Siegel's home state. With such a choke hold on the insurance market, it is very difficult for physicians to selectively opt-out of individual plans within a payer's portfolio, and in some cases they have no choice, it's all or nothing depending on their contract.  Siegel says her group has walked out on bad payers before, but that move "is incredibly inconvenient for our patients who have that insurance during the negotiation process."

*Looking for additional strategies for getting paid at your medical practice? Our experts offer eight tips to collect more of what you are owed. Visit bit.ly/tips-get-paid to see their advice.


It's not always easy to deal with insurance companies. It helps to know which areas are likely to cause the most trouble.  Make sure you keep an eye out for these problem areas:

• Rule inconsistency 

• Lack of communication

• Delaying or dropping claims

• Changing contract terms

Erica Spreyis associate editor for Physicians Practice. She can be reached at erica.sprey@ubm.com.

This article originally appeared in the April 2015 issue of Physicians Practice.

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