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A Plan of Attack on Getting What You Owe from Payers


Your team of physicians, administrators and lawyers can help you get what you rightfully owe using data-driven tools.

Part 1 of 2 on getting what you owe from payers can be found here.

Doctors are not attorneys, nor are they administrators. The information attorneys find useful to help you recover from reluctant insurance companies and health plans is within your control, but you may not know how to gather it or present it forcefully without good legal advice. Working with attorneys can help your office maximize its reimbursement.

What you do now

Most offices know how to approach billing disputes with patients. There are the phone calls, the follow-up emails, and – if necessary, the referral to collections. Sometimes the amounts are written off. Regardless, there is a system and you know the process. And when you assign an account to collections, you are content to pay a percentage of recover for a certain amount of legwork. You are unlikely to have a contract with your collectors to bring a lawsuit for uncollected amounts, suing patients is unpalatable.

You don't have a system in place for the commercial payers.  Most offices have administrators follow up with prompt payment deadlines and resubmission (and resubmission) of required additional paperwork, but how many of you have seen successful resolution by way of the internal appeals process?

What you need

Each office should have a system in place to pursue disputes with health plans and insurance companies. And because these companies have lawyers, you need to have lawyers too. You need to be able to gather the sort of information that will make a difference, and present it in a way that will get attention. This requires lawyers, because advocacy is our job. Most important, we can bring actions in arbitration or in the independent dispute resolution process (litigation too, if needed). This can be done in a way with little cost to your office. Don't underestimate the power of the legal system to get results.

Office synergies

The sort of information that lawyers find useful, you will find useful for other reasons. If you invest in the value of data, you will see results in a stronger, more profitable practice.

Track denial statistics by reason

Track your R&C payments in particular by CPT code, date of payment, amount, insurer or plan, whether you have a contract or not, and if you're dealing with an employer plan.

The following is a brief outline of denial issues that often arise in contracted relationships (preferred and otherwise). This is the case especially due to the fact the average office deals with countless products, and these products change yearly. Add to that the fact that the people on the other end of the phone are not often very knowledgeable or helpful.

• Wrong contracted rate

• Denials:

         • Problems with forms:

                • Incomplete/inaccurate demographic information

                • Service covered by another plan/payer

          •  Medical reasons

                • Uncovered service

                • Prior authorization/referral required (get confirmation)

                • Claim already included as part of bundled payment or managed care program

                 • Lack of medical necessity

          • Late submission (not tolled for asserted lack of documentation)

                 • Payers have state-law imposed deadlines for responding to and/or denying claims

                 • Medicare and Medi-Cal have different rates

                 • There are often "good cause" exceptions for delay out of plan

• R&C

• Emergency care

• Non-emergency care

Data driven decisions

When you know what is being denied by whom and on what basis, patterns emerge. Individual claims that might not be worth pursuing may appear to be part of a larger pattern worth addressing. Here is an outline of the advantages to tracking this data:

• You can see what you have left on the table, and with whom

       • Allows you to see if one insurer is underpaying you vs others

       • Allows you to see if one insurer is underpaying you vs itself

• You can determine how to allocate tasks

        • Administrators:

            • Gathering correct insurance information

            • Tracking response due dates and responses from companies and plans

         • Physicians

             • Coding

             • Claim documentation

         • Attorneys

             • Data gathering management; supervision of administrators

              • Claim grouping management with physicians for letters and action

• The world is becoming more data-driven. As is becoming clear from Medicare reimbursement protocols, physicians are increasingly being compared to each other – being graded on the curve. While the days of being paid fair value for your services are long gone, the situation is only going to get worse.

• What do to? Use the data you are being required to use for Medicare to help you obtain reimbursement from commercial payers! Develop a robust database that explains who is paying you what for a given service and use that data to negotiate effectively with others. Data is objective. It speaks, where requests and simple demands don't.

You can do this!

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