Getting Payers to Pay What They Owe You

Part I: Reimbursement disputes with payers require attorneys

Payer reimbursement headaches

Are you leaving money on the table? Does your practice find that payers are denying certain codes or procedures for infuriatingly opaque reasons? Is it harder than ever to keep track of overlapping timelines for providing claim information, supplemental documentation, and provider appeals?

Do you know what percent of your initial claims are rejected, whether that is increasing, and if there are any patterns? Do you know there are steps you can take?

Reimbursement is not debt collection

The first thing to keep in mind is that payer reimbursement is a completely different game than patient collections. They involve different trajectories, demand different skill sets, and require different sorts of support.

Patient collection is a task best suited to your office administrator or staff, with follow-up efforts of a third-party bill collector. Think about it. Patients know you and your staff. They want to pay you -or are at least sympathetic to the small amounts that you seek for copayments and deductibles. They may be receptive to phone calls from your administrator. And they may be afraid of damaging their credit rating should you hand the bill over to collection.

The tasks of reminding, asking, and cajoling are also well suited to your administrative staff. Your staff greets your patients at the door, schedules them on the phone, and confirms insurance coverage details already. It is natural for the person who is responsible for discussing deductibles and copayments to follow-up regarding outstanding amounts due.

When the phone calls are done – and who better to know that point than your administrative staff – it is time for the collection agency. There are many bill collectors, and they know what they're doing. They know what to say and when to call (which may well be after your office is shut down for the day). You undoubtedly have a contract with one of these firms right now for a reasonable percentage of the recovery: they are motivated to go fishing, and they know when to cut bait.

None of this is true for payer reimbursement.

Reimbursement is cut out for lawyers

Insurance companies and managed care organizations do not want to pay you. That is why you need a lawyer on your side.

Unlike patients, who would rather not pay, payers are actually tasked to oppose your requests for payment. They are not set up to be receptive to your staff when it calls: they are notoriously understaffed, so your administrator can spend hours on the phone, only to repeat the same process the next week. Moreover, payers are complex organizations, with Byzantine rules. You cannot be sure that you have learned just what it is that the company wants from you, much less that what you're about to spend time gathering is helpful to your position. The representative with whom you speak may not even know.

The system is simply not set up for your administrator to be very effective at this. And the result is both that you have the wrong person tasked with this project but you are wasting time that would be more productive if your administrator were focused elsewhere. What is your administrator doing while on hold? Not speaking to a patient - that's for sure.

To be sure, many administrators are skilled at wringing money from insurers and health plans. But don't be too confident that is the best that can be done. Claims reps have limited bargaining power. And negotiation is always more effective when combined with a credible argument that if you are not treated properly, you will escalate the claim to the next level.

And just how productive is your system? When is the last time you were successful with an internal plan appeals process? When do you know to get an attorney involved and when it may be too late?

The simple truth is that attorneys who represent physicians know your issues at least as well as your administrators and can advocate on your behalf with greater power. This is because they are also knowledgeable about and able to bring a claim for reimbursement before a neutral arbitrator. That is where most of your high-dollar claims will have to go if they are to be resolved in your favor, and you need to know how to prepare the right record for success.

Lawyers can also work with your administrative staff to identify patterns of unfair denial or underpayment. Administrators have the data; lawyers can bring home the bacon.

Next up:

Part 2: A plan of attack