Prodding insurers? Use patient power

May 20, 2005

Can't get a health insurer to pay up? It's customers might get better results.

When FP Frederic F. Porcase's primary care group in Jacksonville, FL, was having difficulty getting claims processed because an insurance network hadn't put the group's new tax ID number in its computer system, the group asked patients to enter the fray.

"We posted a sign in our waiting room with the representative's name, and told patients that if their claims were processed out of network to call this rep," says Zanda M. Chandler, the group's finance director. "The insurer was furious with us, but the tactic worked: Our new tax ID number was entered hours after patients began calling." The group had been trying to get the number changed for nine months.

"Doctors don't realize how much power patients have with insurers," Chandler continues. "We often set up conference calls with third-party payers and patients when the insurer tells us one thing and the patient another. That almost always achieves good results."

While some patients are savvy complainers who can get the most recalcitrant insurers to pay up, others need coaching on who to call, what to say, and how to say it. Here are some guidelines.

A few tricks of the trade "If you're asking a patient to help collect from an insurance carrier," says Judy Capko, a practice management consultant in Thousand Oaks, CA, "give her the tools to do it." These include the carrier's customer service number and a copy of the claim so she'll know what's outstanding and the date(s) you submitted your charges.

"Be sure to get a commitment from the patient," Capko adds. "Ask when she'll pursue the matter and when she'll get back to you. And then follow up."

Bringing patients into the insurance payment process can be as enlightening to them as it is helpful to you. As FP Katherine Martin of Harrisonburg, VA, points out, "Most patients are indignant when they learn that I haven't been paid for my services, especially when they have benefited from them. They'll gladly call the insurer. After all, it's in their interest, too, that I stay in business."

In San Jose, CA, general practitioner Liza Shiff gives patients a choice of submitting their bills to the insurance company or letting the practice send the bill. Often, Shiff says, if the patient submits the bill, the reimbursement check is higher. "I guess the companies don't want patients to know how little of their premium dollar goes to their physicians."

In Shiff's view, the process of insurance billing is unpredictable and inconsistent. "In an effort to enforce unity, my patients and I obtain approval before an expensive procedure-whether or not the plan specifically requires it-and we're persistent in getting long-term approval for meds so that we're not tripped up by formulary changes. My office always has forms for each company on hand, so we can fax them in front of the patient and give the patient copies. Then, when the patient calls, he can assure the customer service rep that we've done the necessary paperwork."