It pays to make friends with payers

November 18, 2005

Health-plan employees are people, too. That's good to keep in mind during the next call about a denial.

When your biller phones a third-party payer about the latest under-paid or denied claim, the conversation doesn't have to resemble the new TV show about Iraq called Over There-all verbal gunfire and explosions.

Okay, maybe it won't be 7th Heaven, either, but the relationship between your employees and an insurer's can be civil, constructive, and a boost to your bottom line. Many practices have learned that when it comes to collecting their money, they attract more flies with honey than vinegar. The honey can be something as simple as a Christmas card or phrasing of a complaint tactfully.

"We come from the viewpoint that the insurer is not our enemy," says Bonnie Carlson, administrator of Denver Allergy and Asthma Associates.

Do your homework before dialing

These telephone beehives are abuzz with customer service representatives who earn salaries between $20,000 and $34,000 a year. Turnover is high, the work is advertised as "fast-paced," and reps get chewed out occasionally by irate doctors and their employees, says Sharon Rentze, who oversees several occupational medicine clinics in Missouri. "When a surgery claim involving a lot of money is denied, the doctors tend to take it very personally."

Some insurers have moved their call centers overseas, subjecting billers to communication barriers (read: heavy accents). A bigger hurdle, however, is getting someone on the line in the first place. Billers must navigate automated phone systems and endure holds as long as 30 minutes before they reach a customer service rep, says Costello. The rep is assigned to the caller randomly. The caller typically can discuss only so many claims-anywhere from three to 10, depending on the insurer-during one call. That restriction creates a hassle when 20 problem claims are stacked on your desk. "When I max out, I hang up and call the toll-free number again," says Costello. (For more call-center war stories.)

The first step in getting results from a call center is gathering all the facts about a claim ahead of time. "You want the explanation-of-benefits form, the chart, the actual claim, and perhaps a report on it from your practice management system or clearinghouse," says consultant Rosemarie Nelson in Syracuse. Don't expect sympathy if you haven't done your homework, adds Amy Taylor, the administrator for a Syracuse cardiology practice who used to work for a health insurance company. "That would make our reps a little cranky," she recalls.

Once you have someone on the phone, carefully choose your initial remarks. To brush up on your third-party manners, read "What you should never say to a claims rep".