Getting what you're owed by third-party payers

Key Points

While some of these pledges have been kept, virtually any physician who contracts with third-party payers knows that significant problems remain, including the ability to get fairly compensated in a timely fashion. To ensure that you get paid for all that you do, Medical Economics convened a roundtable at the 2008 meeting of the National Society of Certified Healthcare Business Consultants, which took place in St. Louis in June.

In addition to describing some of their physician-clients' experiences with third-party payers, the four practice management panelists recommended strategies they have found most effective.

1 FIGHT BACK WHEN PLANS DON'T PLAY BY THE RULES

Kathryn Moghadas, president of Associated Healthcare Advisors Inc. in Fern Park, Florida, relayed a situation she encountered in her role as compliance officer for a billing service.

"I recently received a query about a solo ob-gyn facing repeated claims denials from a particular health plan," Moghadas says. The denials were for fetal non-stress tests, a service that is not part of the normal obstetrics package.

"It's in their contracts, it's on their website, and we should be able to bill for this when a patient goes into pre-labor contractions," Moghadas says. "The doctor used the correct CPT and the ICD-9 code for false- labor pains, provided documentation indicating that the test was a medical necessity, and submitted the claim according to the contractual relationship."

Still, the claim was denied - allegedly because it's part of the global OB package.

"Except that when we look at the global package, we see that it excludes the fetal non-stress test, which is a carve-out service," Moghadas notes. The next step was an explanatory note, but it, too, was kicked back. The insurer's response: "Since you billed for the total OB package, you can't be paid for this." She directed the health plan to its own website and literature, with a request that the determination be changed.

After yet another denial, Moghadas got on the phone and read directly from the plan's website to the individual on the other end, who promptly agreed to reconsider. "Now I'm excited, thinking that I'm finally getting the insurer to listen to me," she recalls. The arrival of another denial dashed that hope.

The claim was originally submitted in April 2007, and the final denial arrived in December. That's nine months wasted trying to correct an error, to no avail. "We're continuing to chase this because, although it's just one claim, we've all seen how one claim gets extrapolated to equal hundreds and hundreds of claims," she says.

The economic impact of the claim, which was for $120, is staggering.

"Because we had to use someone at a supervisory level (earning $17 per hour) to do the denials, and it took close to three hours of that employee's time, the billing service is already out $51," Moghadas points out. "If the insurer had approved the claim, it would have paid just $68. After the service was reimbursed for the time spent and received a percentage of the payment, [about] $20 would be left for the doctor."