Playing To Win At The Insurance Game

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. • Assignable clauses for possible silent PPO activity. Doctors and hospitals lose millions of dollars ever year on unauthorized discounts from illegal silent PPOs. Your contract needs to have a clause that prohibits the plan from “assigning” your claim to another unauthorized discounted network. Later in this article, I will discuss how you can recognize whether a silent PPO has targeted you on any of your claims. • All products clause. Although this is not as popular as it once was, you need to make sure you can negotiate separate business terms for each product the plan offers. In other words, you do not want to have to take the poorly paying HMO in order to get into the better paying PPO. You also should have the ability to refuse certain products in the plan. • Late payment of claims. Many payers now have provisions that will deny your claim if it is not filed in a “timely manner.” This has been a source of great frustration among physicians in trying to prove a claim was indeed filed in a timely manner when the plan denies receiving it. There should also be contract language as to what defines a “clean claim” and when that claim should be processed. Given that many states have “prompt pay” bills in force, the time frame to process claims should be no more than 30 days. Some insurers have made a game out of finding legal loopholes to stall these claims or claim they are not “clean” in order to get out of paying legitimate claims in a timely fashion. Essential Tips For Holding The Plans Accountable In our practices, we all see various day-to-day problems and need some practical solutions to help reduce their “hassle factor.” Reducing these common headaches can increase your bottom line. • Silent PPOs. As mentioned before, a silent PPO is where a network subcontracts with a managed care plan you are already contracted with or where a PPO contracts with an indemnity (fee for service) plan that you do not have a contract with and takes an additional unauthorized discount. You can prevent yourself from falling victim to this by both making your contract unassignable and making sure the EOB you receive on a particular patient lists the managed care plan that is on the patient’s insurance card. For example, if the patient’s card does not have a contracted managed care plan logo on the card yet the EOB demonstrates a discount was taken by a managed care plan not on the card, you have been hit with an illegal discount. To have this repealed, you need to appeal the claim and demand the insurer pay you the full fee-for-service (or percentage of usual and customary) as determined by the plan without the discount that you are not contracted to give. • Constant downcoding/undercoding. This is a constant ploy used by managed care plans to reduce payments by consistently changing the codes you submit without any justification such as medical records, etc. In fact, Aetna just settled a multi-million dollar lawsuit with hundreds of physicians for this practice. Besides appealing these claims individually, I would recommend the following actions if a particular plan seems to be constantly downcoding or undercoding your claims. The first thing you need is your fee schedule for any of the codes you are submitting on your HCFA form. Then batch all of these claims together and send them with a letter to the CEO of the managed care plan with a copy sent to the patients involved, your State Insurance Commissioner’s office and your state’s Attorney General’s office. The letter should state that the insurance company is not acting in good faith by changing these codes without any justification or medical records (providing they never had anything but the claim to go on) to reduce the payments on the services sent in. Let the CEO understand that the insurance company can be sued for these actions. Usually the combination of the letter to the CEO and the knowledge that the patients as well as the insurance commissioner and attorney general’s office are aware of these actions will prompt the insurance company to take action on these claims. After I personally did this, one particular plan ceased downcoding of all of my claims. How To Combat Common Delay And Stall Tactics There are many states that have prompt pay laws for “clean” claims but insurers have tried many approaches to be able to “legally” stall payments of these claims. The only way to accomplish this legally is to report the claim was either lost or not clean because of missing information. Here are some common tactics employed by insurers and how you effectively deal with these problems. • Delayed or “slow-pay” claims. The best way to reduce the slow pay or stalling of claims by a particular insurer is to get your patients involved in the claim process. In my practice, when the patient signs the assignment of benefit form when he or she comes in, a clause states he or she will be responsible for any unpaid claims or denied claims within 90 days. After 60 days from the date the claim is submitted, the patient gets a letter explaining the particular state’s prompt pay law with a statement that the insurance plan is not in compliance. If this claim is not paid within another 30 days, the patient will be responsible for the bill. Subsequently, the insurance plan is getting a copy of this letter with another copy of the claim. Make sure your letter notes that a copy was sent to your state insurance commissioner’s office. Usually, the plans will either promptly pay the claim or they will call you (after the patient calls them to complain) to get any “missing” information from you so the claim can be processed. It’s amazing that an insurance plan with no fax machine will all of a sudden find one so you can fax the claim to them so it can be paid quickly. Some states have aggressively fined plans that have constantly stalled legitimate claims. • Stalled claims due to “missing information.” In this case, some plans unable to pay their claims in a timely fashion will “invent” something that is missing from your claim. Usually, you will receive a form stating that the plan either cannot identify the doctor performing the service or the nature of the service, which is already on the HCFA form. I find it particularly interesting that the insurance company cannot identify the doctor performing the service as myself yet can identify me enough to send the missing information request. What I have done in these instances is to highlight the HCFA form sent to me identifying that the “missing” information is indeed listed on the claim form with a letter to the patient demonstrating that this is nothing more than a stall tactic. I will also demand interest (if your state allows) since the claim was obviously “clean.” I will also send a batch of these claims to the plan’s CEO stating that these stall tactics will not be tolerated and that he or she needs to make sure these legitimate claims are processed according to the state’s prompt pay bill. Once the plan’s CEO sees the patients are seeing this game, usually the game will stop as will these “missing” information letters. • Emergency visits of necessary DME supplies on HMO patients without prior referrals or authorization. For those of you who see HMO patients that come in your office without referrals, you are faced with either turning the patient away or risk treating them without getting payment. In an emergency situation, this could present a problem with your being accused of not following the standard of care. In a case where an Aircast/BK Walker, etc. is required, you also run the risk of not being reimbursed for an expensive piece of equipment. The way I have found to combat this is to have the patient sit on hold with his or her insurance company while in your office until a supervisor gets on the line. Not only does the patient see how time-consuming this can be, you do not have to tie up your staff for a patient who came in without the necessary referral. Once the supervisor gets on the phone, you can tell him or her there are two choices. The supervisor can either approve the treatment on the spot (he or she knows the patient is on the line as well) or the patient will be sent to the local emergency room. In this scenario, the plan will not only have to pay for the treatment but the emergency room visit as well. In most cases, the plan will approve the treatment since it knows the expense will be a lot greater (not to mention getting the patient upset at the plan) if the patient has to go to the emergency room when he or she could be treated right there. If the plan tells you to send the patient to the local ER, you could offer a “cash adjusted” fee (never discount) for the service. After all, since the patient does not have a referral, he or she will be responsible anyway but since the patient’s plan is telling him or her to go to the ER, it would be pretty unlikely the patient would sue you for not treating him or her. Final Words As health care premiums continue to escalate, managed care companies have looked to new and creative ways to reduce their exposure to claims. Unfortunately, many companies have used some unfair methods to stall or deny legitimate claims. In some cases, by telling the patient the doctor “coded” wrong or something similar, the patient blames you or your staff for the claim not being paid. It is up to us to be proactive in these situations and get our patients involved so they can see that we are not at fault here. By using some of the aforementioned techniques, we can reduce these unfair delays or denied claims. Also, by understanding what your contract says, you can take the first steps to make sure you are treated fairly in getting your claims paid in an accurate manner. Making sure your contracts have the necessary language will at least give you some legal options in cases where you are being unfairly treated. Dr. Frankel is the Co-Chairman of the Insurance Committee of the Illinois Podiatric Medical Association. He is the President of the Associated Foot And Ankle Specialists, IPA, a 60-member podiatry IPA in Chicago. Dr. Frankel is also a member of the Socioeconomic Committee of the American College of Foot And Ankle Surgeons and lectures frequently on practice management and insurance matters.

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