Playing To Win At The Insurance Game

Author(s): 
By Neal Frankel, DPM

Who would have thought that when we finally went into practice after years of podiatry school and residency, we would be more dependent on third party payers for our existence than our patients? In fact, recent studies have indicated that, on the average, we spend one-half to one full hour per patient on paperwork and insurance matters. For many podiatrists to whom I have spoken, the “hassle factor” of trying to get paid from insurance companies seems to be the primary reason many of them are not happy with private practice. Keep in mind this is a game of sorts. The insurers want to keep the money and we want to get paid in a fair and timely manner for our services. However, keep in mind that for every month an insurer can delay its payouts, it can make millions of dollars in interest on the money it still retains. It would be nice for us not to have to pay our rent and other office expenses every month so we too could make money on the money we keep. Unfortunately, we do not seem to be able to enjoy this same luxury. It is amazing that most of the doctors I lecture to have never even seen the contracts they have with managed care companies and insurers. Your managed care contract can determine how you are to be paid, when you will get paid and of course, more importantly, how much you will be paid. Many doctors do not even know which plans they are contracted with when you ask them. How can their office know if they are getting paid correctly or not if they don’t even know who is supposed to be paying them? Now many doctors are contracted through IPAs affiliated with their local hospital, but you still are entitled to go in and look at the contracts or at least see what they say. Stay On Top Of These Key Contract Provisions Here are a few of the most important issues you should look for when reviewing your contract and the language that should be included so you can be a little more confident that you are not being cheated. • Provisions that change fee schedules without notice. It is very important that you be given the opportunity to approve or deny any fee schedule changes prior to their being effective. • Lengthy wait times to terminate or negotiate a contract. I know several podiatrists, who after terminating their 50 cents on the dollar HMO contract, still had to see those patients at a loss for six months. You do not want a time frame either to terminate or renegotiate a contract greater than 90 days from the date of termination. You should be able to renegotiate a contract without terminating every year. • Provisions that require you to comply and obey with all or any future policy changes. For obvious reasons, you want the ability to agree to any policy changes before they are implemented. The last thing you want is to have to give free foot exams on any and all patients who call you because your contract forces you to. • The ability to collect for “non-covered” services. Out of the entire contract, the language for this is the most important. You need to have the right to bill the patient for a service that is not covered by the plan. This should not be confused with being able to bill a patient for a service deemed “not medically necessary,” which most contracts will not allow. To my knowledge, no doctor has ever lost (in court) the ability to collect from a patient on a service that was not a policy benefit under the plan. Surely, you would have a difficult time billing the patient if your contract forbade you to collect for a non-covered service. • Know fee schedules by absolute values or by what percentage of the base year the schedule is being computed on. This is very important. Knowing what percentage of Medicare reimbursement your fee schedule is based on means nothing if the base year had the lowest reimbursement of any surrounding year. In other words, 120 percent of a 1997 base year may be lower than 100 percent of 2000 Medicare. Of course, if you knew the absolute value by any CPT code, you could see if the contract was worth signing in the first place. The bottom line is if you do not know what your contract is going to pay for a given CPT code, then how could you possibly know whether you are being paid correctly for your claims? Doctors lose thousands of dollars every year on underpayments because they have no idea what they are supposed to be paid.

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