MCOs denying your claims? The louder you squeak, the more grease you get
MCOs denying your claims? The louder you squeak, the more grease you get
Thoroughness, persistence, follow-up pay off in appeal victories
Does it seem like the number for your managed care claims office is 1-800-WON’T-PAY? If yours is like most medical offices, your staff struggle daily with claims denials from managed care organizations. And when you are dealing with a dozen insurers, which is common among practices in areas with heavy managed care penetration, claims denials can be a source of long-standing frustration — as well as hurt your bottom line.
When it comes to appealing denied claims from managed care companies, you might be advised to remember the adage: "The squeaky wheel gets the grease."
"Persistence is the key to having a successful appeals program. Pursuing denied claims definitely will pay for that staff member’s salary," says Tammy Tipton, chief executive officer of Appeal Solutions, a Lewisville, TX, health care consulting firm specializing in reimbursement issues.
If you establish an aggressive appeal position, your office will be recognized as one that appeals claims, and at some point you’ll get fewer denials, Tipton points out.
"There are a lot of honest mistakes and a lot of gray areas," she notes.
In today’s managed care environment, you need a well-trained, well-organized, experienced team in your office to follow up on insurance accounts, Tipton suggests. Your business office should have a structured follow-up plan that includes guidelines on how often you send a bill, when you send out reminder letters, when you send out an inquiry letter to the insurer, and when you contact the insurer by phone, adds John Nosek, MPA, CMPE, executive director of Greensboro (NC) Orthopedic Center.
The first step in the appeals process is to find out why your claims were denied, suggests Gary Hickerson, director of operations for Sarasota (FL) Memorial Hospital’s 440-member PHO.
Before you take it up with the payer, make sure your claims were properly submitted, he asserts.
"There’s no question that we sometimes see accounts receivables that get into no man’s land, with the insurance company saying we need more information or this isn’t the appropriate code. The key to getting paid is having good basic billing policies and procedures established within the practice," Nosek says. (For tips on how to make sure your claims are properly submitted, see story above.)
Hickerson tells of one payer that wanted to make sure a member didn’t have a pre-existing condition before paying the claim and insisted on five years’ worth of medical records. However, the patient had moved to the United States from China only two years earlier, and there was no way to get five years of medical records. The insurer eventually paid the disputed claim.
Once you’ve filed an appeal, don’t stop there. Follow-up is an important part of appealing denied claims, Tipton says.
"If you think carriers lose a lot of first-time claims, they lose a lot of appeals papers, too," she adds. Make your appeal a multi-part process, Tipton says. If you are denied on the first level, take it to a higher level or try to get a more appropriate person within the company to review it.
Don’t forget to appeal on claims that are only partially paid, Tipton recommends. "There are significant benefits to collecting partially paid claims. Your staff should be proficient enough to recognize an underpayment and appeal it," she adds.
Because of its large size, Hickerson’s organization has been successful in getting some payers to send a claims representative to their office with a computer terminal to adjudicate claims right in the office. "Once we know they really are making mistakes when they deny our claims, we have insisted that they bring the claims representative to our office and resolve the issue, and some are willing to do it," Hickerson says.
But, he adds, "that doesn’t mean the problem is going to stay fixed."
To get a payer’s attention, Hickerson’s PHO insists on payment of interest on delayed claims. The Florida Legislature has required payers to pay interest on claims that are not paid within 45 days. "If we insist on interest, they’ll move a little faster," Hickerson says.
Claims that are six and eight months overdue are not that uncommon, he adds.
Getting a payer to agree to pay interest if the claim isn’t processed in a timely manner is "a fabulous thing," but most payers won’t agree to it unless it’s the law or part of the contract, Tipton adds.
Most state insurance codes have built-in penalties for carriers who don’t pay in a prompt manner. However, they typically apply to commercial insurance and not to individual managed care contracts, she says.
It’s difficult to get favorable terms built into a managed care contract, but Tipton suggests trying to incorporate any measures that affect commercial insurance in your state.
"If your state legislature has put it in the insurance codes, it will serve you well to put it into your managed care contracts," she says.
Here are some other suggestions for appealing denied claims:
• Make sure your staff know the proper person at the insurance company to call on for help.
• When you resubmit claims, try to get the payer to help in the resubmission process. Ask for help in submitting the claims.
• Look for tools to help you manage your claims and your appeals, Tipton says. Her company and a number of others offer software to help with appeals.
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