Denied claims and late payments take their toll on practices
Denied claims and late payments take their toll on practices
But three states are fighting back with prompt pay legislation
In the last three years, David Rogers, MD, a gynecologist in Allen, TX, figures his income has dropped by 30%. He hasn't given his staff any raises or bonuses in that time, and his personal salary has gone down. Rogers lays the blame squarely at the feet of managed care organizations (MCOs), who have - in his opinion - contrived to deny and delay payment for legitimate claims in a myriad of ways.
But for Rogers and his counterparts in Texas, help could come from a bill passed last year requiring health claim payers to pay up in a timely manner. New Jersey and New York have passed similar prompt-pay legislation.
Bradley Reiner, manager of payer relations at the Austin-based Texas Medical Association (TMA), says he can't think of a single payer that hasn't been the subject of a complaint from TMA members about chronic late payment and claim denials. "They give every reason in the book," says Reiner. "They want more information; they say they never got the claim."
The Texas law, which went into effect in September 1997, has yet to be enforced. But in the near future, Reiner says the state's Department of Insurance is expected to take actions against those companies that don't follow the new rules, which include payment within 45 days. If more information is needed, such requests must be made within 15 days of a claim's receipt.
Reiner says the Department of Insurance is currently sending notices to payers telling them the law will be enforced. "I expect in the near future there will be a precedent-setting case," he says.
Payer sources in Texas could not be reached for comment.
Meanwhile, the situation for Rogers and many of his counterparts has not changed. MCOs even have a new and very interesting way of delaying payment, he says - closing offices and not having their mail forwarded. Rogers says he often gets bills to payers returned stating there is no forwarding address. When Rogers calls the payer, they mention that the claims office has closed or moved.
Another common method of denying claims, he says, is the use of rebundling software by payers. Rather than using this software to weed out inconsistencies - such as a male patient getting billed for a hysterectomy - Rogers claims they are using it to exclude certain items.
For instance, when Rogers used to do routine urinalysis tests, he would be paid about $4. Now, the rebundling software refers to that charge as something incidental to an office visit and refuses payment. "They just do these things unilaterally. They have assigned a relative value of nothing for that service. In my solo practice, we had over $6,000 from those tests over the course of a year. If every carrier didn't pay for it, we would have a $6,000 decline in the bottom line," he says.
Other companies use modifiers for coding so that when multiple procedures are done, they pay for the cheaper one, Rogers adds. For example, if Rogers performed a hysterectomy and noticed an inflamed appendix in the patient during the procedure, he would remove it. In the past, the customary thing to do was to charge half the normal fee for the second procedure - in this case, the appendectomy. Now, payers pay for the appendectomy because it is the cheaper charge, even though it was the secondary procedure and reimburse the hysterectomy at 50% of its normal rate.
Other payers are insisting Rogers bill using standard CPT and ICD-9 codes but then are implementing their own claims coding policies and payments, rather than those that go with the standard codes, he says.
The passage of the law in Texas has not impacted any of the methods used by these companies, Rogers says, although when he calls to complain, he has noted a more civil attitude from the people he talks to. "There is definitely a renewed respect for things that heretofore fell on deaf ears," he says. "They are listening. They have to think before they deny something. And it is a moral victory for us."
And so Rogers has maintained the same strategies to get paid what he is due: He complains, he writes letters, and he appeals. "It does take a tremendous amount of office effort to do this," he admits. "We are lucky. We pay attention to what is happening, but a lot of offices don't understand what's going on. You have to really comb through the explanation of benefits forms to understand this. Some physicians just see their bottom line is down, but they can't point to why."
Rogers recommends that physicians do the research and then employ his practice of writing letters. "We write to everyone - the employer, the state board of insurance, the TMA. We copy the attorney general office, the department of labor, our congressmen. And we get our patients involved. We will appeal over and over and over again."
One reason for the constant appeals: It costs about a dollar to process - and deny or delay - a claim. But it costs the payer some $30 to deal with an appeal. "If they won't pay, we're going to make it hurt," he says.
His methods have had an impact. One payer hadn't paid claims in five or six months. Rogers sent letters to patients and employers explaining that he would stop seeing patients who used that payer and why. Payments resumed.
"We have to fight this. If we lay down and let it happen, they will find more and more creative ways to not pay us. We have to make it unprofitable for them to do these dastardly things."
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