How to Determine Who Will Go the Distance: Provider V. Payor

MINERVA DEJESUS and AURIANA REYES
Posted: Wednesday, August 11, 2010 8:14 am

It's fair to state that everyone should get paid for a provided service. We pay for food at the supermarket. We pay for gas at the gas station. Our taxes pay for law enforcement to serve and protect. Money is always coming out of our pocket to pay for a necessity or luxury that improves our quality of life. It is the sole purpose we all work, given it's a means to provide for ourselves and our loved ones. While there are many reasons we work where we work, it's safe to state that the number one reason we all do what we do is for money. If we did not get paid for the hours we worked or didn't pay for what things we wish to purchase, it would be criminal.
 
Because we all agree everyone should be paid for their job, it's difficult to understand why the payor does whatever possible to deny the physician reimbursements for the job they provide our community. It's a continuous battle, a 10-round match, a fight that will forever go the distance. In an ideal world, medical billing companies would receive their claims, submit them, and get paid the highest reimbursements each time, every time. However, that's not the case as we fight harder each day for every cent the provider deserves for a job well done.
 
The following are just a few examples of the ridiculous ways insurance companies try to get out of paying a perfect claim:
  • Payor tried to deny a claim because they stated the provider was not in their system. This is impossible, given the fact that the insurance company has paid the physician several times prior to this claim. Once we made the call and pointed out the obvious, the claim was fully paid.
  • Payor tried to deny claim stating the patient was no longer eligible for benefits. The insurance company stated the patient's benefits ran out August 23, 2010. We submitted the claim May 10, 2010. We repeatedly asked: "Did you say August 2010?" They replied with confidence. "Yes miss, their benefits ran out August 2010." So we kindly reminded them that it was June; August has not arrived, and the claim was submitted in May. Claim was fully paid. 
  • Payor tried to deny claim stating the patient did not have benefits for a required procedure. This is the same insurance company that gave an authorization code 48 hours prior to surgery. An authorization code is required to schedule the procedure. Why would you give an authorization code if you were not going to cover the charges? That claim was fully paid when the authorization they provided was pointed out to them.
  • Payor tried to deny claim because their system stated the patient no longer had benefits and was not eligible for medical care to be covered. When the call was made to request the termination date, the claim specialist working for the insurance company looked up the patient's account to discover that the patient was active in the system. Claim was fully paid.
 
There is a specific time allowed to appeal these claims. If you push these claims aside and don't appeal right away, you may not have a choice but to write the deserved amount off—even if the payor is wrong and the claim is flawless.
 
This is a sneak peek into the time-consuming phone calls a medical biller must make regarding unpaid claims. Did you know that a phone call to an insurance company averages approximately 45 minutes, and that 70 percent of the population with insurance have no idea what their coverage is? Some office managers that also do the medical billing lack time during their busy day to make these calls, which means it's more than likely that if the call is ever made, it will be after the time-allowed deadline. As a result, the practice loses revenue and it affects the physicians' bottom line.
 
The insurance company is hoping that they will get away with this nonsense. They pray no one is paying attention because while you're preoccupied with other duties, the pennies are adding up and ultimately taking away from the physician who has worked so hard providing care to the public. Everyone deserves excellent medical care, but when the patient receives that wonderful care and the physicians don't get paid for the services provided, it's criminal. Physicians need to take care of themselves and their families. It's a tough task to do when you aren't getting paid. It is fact that if any of us did not get a check to cover 40 to 80 hours of hard work, we would all find another job.