Practice Management Alert

Your reimbursement problems get a dose of expert attention

Dealing with the obligations, provisions and requirements of many different insurance companies is one of the biggest billing challenges.

Medical Office Billing & Collections Alert has heard from several readers who express frustration in dealing with the demands of a diverse collection of carriers. Top on the list were 1) dealing with patient contract obligations and 2) managing timely filing limits. Here our experts step up to offer essential advice that will reduce your stress and keep you from scrambling for information.


Complaint #1

Practices should not have to assume responsibility for an individual patient's insurance policy problems. A New York subscriber says his most recent tale of woe involved supposed nondisclosure by an insurer of a rider that limited reimbursement on certain surgeries. The patient claimed he was never informed of this provision and therefore refused to pay when his insurance denied the claim. After the patient filed a lawsuit, the carrier decided to pay in full. However, the office's costs for participation in the lawsuit basically negated the payment.

And the experts say ...

Providers are certainly not responsible for knowing the details of every patient's individual policy, says Wanda L. Adams, president of Wanda L. Adams and Associates Inc., a consulting firm in Festus, Mo. Neither are they responsible for making sure patients know their own policies' provisions.

Unfortunately, patients often have a procedure without first reading and understanding their insurance coverage. The patient is then angry and frustrated to discover that the procedure isn't covered. Don't be fooled or guilt-tripped into thinking this was your fault. As a provider, your only responsibilities are to:

1. Know what you are obligated to do within your own contract with each insurer. Standard responsibilities usually include taking the patient's payment (the amount allowed) and billing the patient for anything else not covered. Practices need to make sure they understand their contract with payers, Adams says. And, you need to inform all patients of their financial obligations to the practice. This can be done easily at check-in by handing out a sheet that outlines payment policies and procedures.

2. Keep on file a copy of the front and back of each patient's insurance card so you can review any pertinent information before providing a surgical procedure or an admission to the hospital. "If it's a procedure that needs to be precertified, the office needs to know when to call the insurance company to precertify a case before they proceed with the surgery," Adams says. If precertification for hospitalization or surgery is required, you can usually find this requirement on the back of the patient's insurance card.

3. Explain to Medicare patients what their out-of-pocket expenses will be for procedures that cost $500 or more. This applies only if you're a nonparticipating provider for Medicare and will not be accepting assignment on a claim. You'll also need to have the patient sign a form saying he or she was informed of the expense.

Complaint #2

A Connecticut subscriber's billing office has problems completing claims within the various time limits of the carriers. As a radiology practice, they are very dependent on the hospitals for information needed to file claims. They have several filing limits that are 90 days and even one that is just 30 days. This makes it very difficult to file things on time, and the variety of filing limits only adds to the confusion.

And the experts say ...

To master your many filing limits, make a chart that lists each carrier's timely filing limit, and work on the claims with the shortest limit first, says Tammy Trench, CPC, A/R technical adviser at Apex Practice Management in Oklahoma City. Obtaining a filing limit is easy - just ask the insurance representative next time you call to check the status of a claim. To keep things straight, Trench also advises you to:

-  Separate your claims by insurer so you always know which ones need attention first.

-  Keep an eye on the progress of claims you know you'll need to work most aggressively.

-  Do your billing on a set schedule to avoid timely filing denials.

-  Run regular A/R reports and call to keep up on the status of claims, especially the ones that have a short filing limit.

Additional Options: If hospitals and other entities are slowing your claims process by not getting test results and other information to you on time, work on improving communication. Make contact with a specific person in the hospital billing office to help the information transfer process.

If possible, you can consider renegotiating your contract with an insurer to extend the timely filing limit, says Kent Moore, manager of reimbursement for the American Academy of Family Physicians in Leawood, Kan. When signing on with a carrier for the first time or as a renewal, remember to review the timely filing limit and determine if the filing limit is reasonable, considering the hospitals and other entities that you depend on, Moore says.  

See Reader Question: Use Proof of Filing to get Your Claim Paid, for tips on when a payer says it never received your claim.