Does it seem to you that the primary mission of insurance companies is to frustrate doctors? That frustration results in more money in the insurers’ coffers, because when you give up on a claim, the insurance company comes out ahead.
Insurance companies use a number of strategies to delay and deny claims. Here are five — along with actions you can take to get what you deserve.
1. Time-consuming collection calls. Insurance companies utilize electronic (automatic) phone systems that callers find confusing and time-consuming to navigate. The goal of these phone-answering systems is to block your staff from speaking to a live person.
If you manage to get through the electronic system, you are typically left on hold for long periods of time, some-times more than 30 minutes. And sometimes, the system automatically hangs up on you after the hold period.
This is a significant problem. With an average call costing 30 minutes of staff time, a full-time collector can make only 15 to 20 calls in one day. This small volume of calls is not enough to warrant the expense of a full time staff position and is certainly not enough to make a dent in an open accounts receivable.
Solutions: Any time you or your staff person speaks with a live person at an insurance company, ask for a direct number or extension. If this information is not given, ask for a detailed explanation, including phone numbers, of how to reach the claims area without going through the electronic system.
Insurance carriers often make these numbers available — but only to those who ask.
Another solution is to contact the home or corporate office of the insurance company. You can typically get these phone numbers from the company’s Web site. Phone numbers to the corporate office generally do not put you into an electronic system.
Calling the home office and asking for the president of the insurance company will almost always earn a call back from someone who can assist you with your problem.
2. Down-coding and bundling. Insurance companies regularly down-code office visits and manipulation levels with the expectation that most practices cannot support the level billed and will do nothing to fight the change.
Insurers also attempt to bundle chiropractic service codes together (such as 98941 manipulation and 97140 manual therapy technique) in order to avoid paying an itemized fee for service.
Solution: Realize that you are entitled to be paid for each of the services you actually render unless you have signed a contract dictating other terms. Once you are certain that you are legitimately entitled to the money, contact the carrier to have your claims reprocessed.
If you are not able to get a claims representative to help you because the company’s computer is programmed only to bundle these codes, speak with a claims manager or call the home or corporate office for assistance.
Note: The substance of your treatment notes is more important than ever. Make sure that your treatment notes itemize the services performed and all the regions adjusted and medically support the need for each service.
For office visits, list the proper time, type of history, type of examination and type of decision making to support the E&M code level billed.
Select diagnosis codes that support the level of manipulation billed. If your codes do not match, the bill will be down-coded.
3. Lack of medical necessity. Insurance carriers deny claims, saying they lack “medical necessity.” Insurers assume that most practices cannot support the need for care and will do nothing to challenge the decision.
Solution: In cases in which medical necessity is an issue, refer your patient for a consult with an appropriate medical doctor, such as an orthopedist or a physiatrist who can support the patient’s need for continued chiropractic care. Provide detailed treatment notes to show medical necessity.
4. Direct payment to patients. Insurance companies send checks to patients rather than to the chiropractor’s office.
Solution: Some insurers may legitimately pay patients directly instead of assigning payment to the practitioner. This occurs if a health-care provider is not in-network.
However, as you have a valid signed assignment of benefits; you are entitled to receive the payment directly from the carrier, who must honor this assignment.
If the company sends the check to the patient and you are unable to retrieve the check easily from the patient, immediately contact the manager of the claims area of that carrier to have a check reissued.
If you cannot reach a manager, call the home or corporate office for assistance.
5. Prolonged PI investigations. Accident carriers delay claims by doing prolonged investigations, thus hindering a practice’s cash flow.
Solution: Know your state law. Most states have regulations that dictate the time frame in which an investigation must take place.
If the regulation is violated, call the carrier and quote the regulation and the carrier’s noncompliance. When you make the call, talk to a manager at a higher level than a claims representative or adjuster.
Most investigations are simple and can be completed in very little time. For example: An investigation concerning a patient’s actual involvement in an auto accident should not take three months to complete.
A copy of the police report that lists the patient is sufficient proof. To facilitate a situation such as this, acquire a copy of the police report and send it to the insurance company. Sometimes you have to take measures into your own hands to protect your cash flow.
Don’t take a delay or denial of payment lying down. Persistence is key — and money in your bank account.
David Winter, the CEO of GLM Healthcare Services, Inc., has a degree in finance and law. GLM consults with practices on topics such as billing, collections, healthcare practice income generation, and healthcare practice set-up. GLM also does hands-on billing and collections for healthcare practices directly from insurance carriers. To contact David Winter or GLM Healthcare Services, Inc. call 561-338-3150.