Taking the Lead with Insurance Companies

After emerging from a very stressful and difficult week regarding payment from a large payer, I've learned a few important lessons that I'd like to share with you now.

We were going through a typical revalidation process and were days away from getting that final document, when everything went sideways, upside down, and swirling into some black abyss. The payer (actually a subcontractor for the payer) lost all traces of our company's information in their system. Poof! And it was gone. To get this information back into their system took the better part of 45 days. I'll spare you the rest of the details, but suffice it to say, it appears we are now moving forward once we took legal action.

As I reflect on lessons learned, I think the most important one that keeps coming up is: "When is it time to elevate your complaint to a supervisor or above?" That answer is: The first sign of trouble. Not the second or sixteenth, the first.

This is your medical practice and business to protect, health insurance companies do not have the right to hold you hostage to their rules. If you are experiencing any difficulties with an insurance company be sure to follow these guidelines:

• When speaking with a representative, always ask for a reference number. Log the date, time, and name of the person you spoke to. Also include a detailed summary of the conversation.

• In the event your request was not completed or you are not satisfied, the next call should be to a supervisor. Don't delay this step. You're not being mean, this is business, and you have a right to get correct information, payment, or revalidation in a timely manner. Your practice should never be threatened by the lack of action from any insurance company, no matter their size or "weight" they carry within the market.

• Know the payer's grievance process and get that moving immediately. Show them you are not going to sit back and just "wait it out."

• Find your state's governing office (insurance commissioner) that will stand with you against recalcitrant insurance companies or payer subcontractors. They are there for a reason and extremely underutilized.

• Retain legal help and have a detailed letter ready to go if needed.

By all means, know your practice's worth and don't risk that by behaving passively when it comes to your revenue stream. For too long physicians and their staff have tolerated bully tactics by insurance companies or payer subcontractors as the standard operating procedure. No way is that ever going to happen again here. We are updating our operating procedures to reflect that aggressive action should be taken in the beginning of a problem, and not wait 45 days to take legal action.