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Understanding third-party payers can go a long way to making your life easier.
Payers are the enemy, so why would any physician want to work well with them? Look objectively at payers, and you'll see that they are in a different industry than healthcare providers. Payers are in the finance business. Physicians are in the healthcare business. Once you realize that, things will begin to make a bit more sense in how they interact and conduct their business with providers.
Though it may be hard to think of yourself this way, healthcare providers are essentially "vendors" from the payers' point of view. The role of providers is to deliver healthcare services, the role of the payers is make sure that they pay as little as possible for providers to do so. This is especially true of for-profit payers, where decisions are based wholly on returning maximum shareholder value, quarter after quarter.
Inevitably, that means bottom-line costs are the driving force behind how payers operate, and they are contained by payers in a number of ways. The most obvious are through provider payment cuts that seem to roll through every year or so. The next are policy changes that bundle procedures or determine which services are "covered" (yet not separately payable). Lastly, the use of automated processes (people are costly!) pushes many processes - from eligibility to claims issues to policy matters - to the providers to "self-serve."
So what does that have to do with your ability to work well with them? Well, once you understand the industry that they live in, you can better understand how you need to work within that context. If you continue to think that payers should just see things your way, you will continue to experience frustration. Here are a few strategies that will keep your processes running smoothly:
1. Utilize provider manuals
Realize that the contract you signed with any payer states that their business, and your participation in it, runs on their ability to make policy and procedure changes. Often the contract will refer you to a provider manual, and these are often updated yearly. So start there and make sure that you understand the processes involved in managing your relationship with that payer. How do you get claims issues addressed? What should you do if you disagree with a denial for service? Who do you contact for credentialing issues? These types of questions can usually be found in provider manuals. You can request copies from the payer directly or go online to their websites and you will most likely find PDF versions there.
2. Know how to find policy information
If you receive a claim denial, before you get on the phone and attempt what I like to call the "1 - 800 - Good - Luck" number, first check to see if there has been a policy change that has affected the way your procedure is now being paid. Go online to the payer's website, navigate to its "medical policies" or "payment policies" section, and look up the procedure to see if there were any recent updates to the policy that may answer your question more quickly and effectively than trying to get answers by phone. If the policy looks fine and there have been no changes, then you can be assured that it is a claims error and work through the defined process spelled out in the manual to get those addressed.
If it is a policy change that's causing the problem and you do not agree with it, bring it to the attention of the medical director at the plan. Call the general corporate number and ask the receptionist who the medical director is for your area. The person who answers the phone can usually give you that information. Qualify your objections using sound evidence and back them up with whatever factual evidence you can (medical articles, studies etc). I have seen medical policies overturned many times once providers take the time to educate payers as to why certain services should continue to be covered.
3. Utilize automated systems
If it is a claims error, determine the size of the issue. Is it just one claim or many that have been affected? If it is just one claim, use the payer’s automated system (via the phone or online) to get it reprocessed. If it is several claims that have been affected, quantify the problem and submit as a project through the payer portal or by sending them to the rep along with a detailed summary of the issue. Payers are large organizations and often have separate claims reprocessing departments. Following the process laid out by the payer is your best way to get your claims problems taken care of as expediently as possible.
4. Let your state regulator know about the problem
Lastly, if you have tried working within the payers' defined systems and still are not getting any satisfaction, contact your state authority or regulatory body and get them involved. Unfortunately, too few providers ever go this route, which means that payers can continue to ignore provider problems and the state does not ever learn about the issues that they could directly help solve. You can find a listing, by state, of these departments under Verden's Prompt-Pay Guidelines Guide, here.
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 firstname.lastname@example.org or by visiting www.theverdengroup.com.