When good enough’ doesn’t cut it anymore
Here are some strategies for lingering claims
Even if you are doing everything you can to avoid delays and denials for claims, you still may have persistent problems. What can you do to solve them?
According to Layton Lang, MBA, chief operating officer of Dallas Surgical Group, a lot depends on the reason given for the persistent problems. If your payers say it is because you aren’t filling out paperwork completely or correctly, you have to remedy the situation by defining what a clean claim is.
If the problem is the time it takes to file a claim, check to see if your computer billing system has a tool that allows you to run reports on pending claims. Run those daily or weekly to see what claims still have to be sent within what time period, says Lang.
If you have to appeal a denial, try using the telephone instead of a letter. That gets the money in faster, he says. However, if you need to send a written appeal, again check your computer program to see if there is an automatic claim letter program. There are also companies, such as Appeal Solutions in Lewisville, TX, that sell software programs designed for just such purposes. (Appeal Solutions can be reached by calling [888] 399-4925.)
You may have to resort to a meeting with the payer, Lang says. "They may be defensive about the situation, but you have to be persistent and find out what the issue is. They may be the problem." It might take several meetings to find out what the issue is, and some payers may promise action but not deliver.
If that happens, you may have to send a formal grievance to your state’s insurance commissioner. The Texas Department of Insurance has an alternative dispute resolution (ADR) program to review grievances. "Here, half the cases are overturned in favor of physicians, so if you have an ADR program, use it," Lang says.
Your state medical society also may have some resources for you. In Texas, for instance, there is a service that mediates between payers and practices. Even if it doesn’t have any services, the state society may trend complaints against payers and should be informed of any problems. Your last resort is to cancel or not renew a contract, he says.
There are few resources for people wanting to learn about this topic, he adds. "This is all just real life. Sit down with your peers. Organize a lunch at your hospital and exchange advice. What works with particular plans? And never assume that the company is right. Do your own research. We have to appeal 40% of our cancer cases because they are so complex."
Pat Aalseth, RRA, CCS, CPHQ, a consultant in Albuquerque, NM, says follow-up on claims denials is vital. "Read the remittance advice you get from the payer and know why they aren’t paying you." She says many will have cryptic codes. "Medicare has a list of some 350 acronyms it uses. You have to be able to look at what they send you and figure out why you aren’t being paid. That means investing some time and effort."
Lastly, be sure you document everything you do — from the date you send the claims to the name of the person you talk to when you call a payer.
Some practices may feel the additional work isn’t worth the few extra dollars they may collect, she says. "A lot of how worthwhile you think it is depends on the size of your practice. But regardless of what you do, you should never dump these problems back on your patients. It will kill your patient satisfaction, and if you don’t understand it, what makes you think they will?"
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