Resolving Eligibility Issues at Your Medical Practice

July 21, 2012

You've seen a patient that you thought had insurance that you accept, but it turns out you don't. What is the best course of action to take?

It happens in every physician office or clinic: A new patient calls in (or a returning patient who has switched insurance), your front office staff calls the insurance company or checks the insurance website and it appears that you take their insurance, so an appointment is made. The patient arrives at their visits, and ends up with a rather complicated diagnosis, or several issues that take up more time than you intended to spend. You submit the claim, and the patient comes in for a follow-up visit. More time spent, and more work completed, perhaps labs and/or x-rays. More claims submitted.

A month later, your billing department receives a denial letter from the insurance company stating you are not contracted with the patients plan. In the meantime, you have seen the patient for two more visits. What is your best recourse of action at this point? Here are some ideas and tips you can use:

1. First, you will want to obtain the original insurance verification completed by your front office staff. They will have a name of a representative that they spoke with, a date and a time. I've mentioned in previous blogs (see below) that when you call into an insurance company they have the disclaimer that “the call may be recorded for training purposes.” Use this to your advantage. Once you have this information, it's time to write a letter of appeal.

2. In your letter, you can list the representative's name, the date and time, and who your front office staff member was, as they ask for their name, as well as your tax ID number. You can state that at the time of verifying, “We were told that the patient was covered and eligible as of 1/1/2012 (or whatever the effective date is) and that the patient had a $20 copay with no deductible (or again ,whatever the benefits were).

3. Once this information is stated, you can now pull out the facts about seeing the patient, how complicated the case was, how necessary the tests that you ordered were, how by providing the top of the line service you have, the patient has improved by 35 percent, and with your current plan of care, you expect this to be 50 percent by month' s end.

4. Be sure in your next paragraph you explain how you are saving the insurance company money. You are doing this by your aggressive plan of care, or by sending the patient home with a comprehensive home exercise program, or sending them to physical therapy instead of recommending surgery, etc.

5. Summarize what you want. You have six outstanding claims that you would like paid in full by the insurance company because:
• You were told, initially, that the patient would be covered;
• You have provided outstanding services;
• The patient is improving due to your plan-of-care; and
• You are saving the insurance company money but utilizing other methods that cost them less in the long run.

6. Be sure to copy (“cc”) the patient on the letter and mail them a copy. Insurance companies do not like receiving complaint phone calls from their customers. They want to keep them happy, and if you want to be paid for your efforts, then enlisting the help from your patients is a must.

After writing a letter like this, and asking for your patient to step in, you have a greater chance of being paid despite not accepting the insurance. Who knows, you might even get a decent contract out of your efforts!

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