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Payers Turning to Patients to Fight Denied Claims


It seems payers want patients, not your medical practice, to resolve denied claims. Here's how to arm yourself and your patients with the information to get it resolved.

Over the past several years, I've been slyly monitoring reasons why insurance companies choose not to pay a particular claim. There is really only so much a front, back, or billing office can do to make sure only clean claims go out. So then why all of the sudden are claims being denied for going over a specified plan benefit that did not exist at the time of the original verification?

I've seen it three times in the past week alone where benefits provided by an insurance company representative at a specified and documented time were grossly incorrect. Unfortunately by the time you are made aware that the benefits were incorrect, it is too late and claims have been denied. What is also new is that the insurance company is claiming that the patient is the only one allowed to call and attempt to get this resolved. Is this because we as professionals are all dialed into the insurance companies' sneaky ways of doing business? That we know how to talk the talk, and walk the walk, and most patients are pushovers and can be intimidated by the insurance company?

I'm not so sure what to tell you about this latest trick other than to get it in writing if you can. There are several companies out there that perform a type of insurance verification for you. They tap right into the insurance companies' databases. Some clearinghouses provide this benefit at a small extra cost. There are also companies like ZirMed who provide several services a la-carte, including verification. Going to the insurance company's website and downloading benefits is also an option, but we've found that those are not always kept up to date. No matter - get something in writing that you can arm yourself and your patients with.

That said, we know they have been cutting back the number of personnel over the last several years and asking you to use their websites and paid services to obtain patients' benefits. Is this a cost-cutting tactic to put the responsibility back onto you and off of them?

Regardless of what it is, it is time to educate your patients. Getting everything in writing and showing that information to the patient at the time of their appointment is the key. If the claim does end up getting denied for exceeding a plan benefit that at the time of verification had not been exceeded, arming the patient with chart notes, the original verification, and some counseling on what to say to the insurance company is critical. It is unfortunate that you have to put the fate of your inflow in someone else's hands, but this is the way the pendulum seems to be swinging.

It is not about the provider or even the patient anymore. They're just the annoying flies in the soup to payers. It is about the insurances companies' bottom line and stock holders. With three of the largest insurance companies (Blue Cross, Cigna, Aetna) making big moves so far in 2013, it is clear that the service end of their business is not a top priority.

Keep yourself aware and in tune with your denials and adjustments that are not contract required.

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