Working with Payers to Avoid Patient Visit Limit Bills

When dealing with insurance companies, which limit do you follow: the insurance visit limit or the number of visits provided by the authorization department? Here's how to make sure your patient does not receive a bill when you have gone over one of these limits.

Regardless of what you think or feel about the healthcare laws that are swirling around the industry, if you have ever interacted with an insurance company, you know that there are many areas in need of improvement within each organization. One of them is the lack of communication between the departments within a single insurance company. It's as if they are all operating on a separate business plan, and none of the departments want to share what they are doing.

Let's take a look at one of these areas. When your front office staff obtains the initial benefits, the insurance company states the patient has an annual visit limit of "x." The insurance company then states to your front office staff that authorization is needed for the visit(s). So, another phone call to another number is made and a completely different set of visit limits are provided. This often happens in rehabilitation medicine (physical, occupational, speech therapy, and home health episodes). Which one does your staff follow and how are they supposed to know? When you ask the auth department, the rep will say something like, "I work in the authorization department, and I am able to authorize 12 visits." They will not even acknowledge the patient has a 10-visit limit, confusing your staff even more.

A rule of thumb to follow: Go with the overall insurance visit limit, and not the authorization visit limit. It seems a little counter-intuitive, but I have seen more times than I can count how many times the insurance limit has been ignored, and the patient will receive a bill for the full charge amount (not your contracted rates with the insurance company) when the authorization was followed instead. This can lead to confusing phone calls with the patient, and regardless of the excellent service you provided, and a very unhappy customer.

Workers' compensation, Blue Cross, Aetna, UnitedHealthcare, Blue Shield, Cigna, and others all do this, and refuse to pay the authorized amount regardless if you have an authorization number. Your billing department can try to appeal, but the claims will still most likely not be paid.

The best part is when your billing department calls and inquires about this, the insurance company will say something like, "we told Dr. Ellemeno's staff that there was a 10-visit limit on the policy, and the patient is aware of this also," hereby passing their inability to communicate internally, as everyone else's fault except their own. Now, when the patient calls (the insurance company's customer), the insurance company lays all of the blame on your office staff. This creates a string of finger pointing that is just a waste of precious resources, and costs you more than perhaps what you would have been paid in the first place.

I don't think it is an accident that the insurance companies operate this way, but they're the ones making millions off of your hard work and desire to heal your patients. Be smarter than they want you to be and learn their tricks that will insure payment of claims.

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