How Healthcare Providers Collect From Insurance Companies and other Payers?
Why Health Plans Don't Pay - Common Reasons for Disputes Are:
- Medically Necessary Treatment - A common area of dispute is whether a treatment was appropriate and necessary. What is medically necessary is often defined in statute. In the state of Florida there is a Patient Bill of Rights, Statute Chapter 409.9131 defines that as any good or service necessary to palliate the effect of a terminal condition or to prevent, diagnose or correct or alleviate a deterioration that threatens life, causes pain, or results in illness. However, contracts often resort to their ow language that may require preauthorization for coverage, prohibits retrospective payment denial on the basis of lack of medical necessity, and sets forth an expedited process for appeals.
- Emergency Medical Care - the level of care is sometimes debated. Generally what is emergency care is determined on what is called "prudent lay person standard", such that if a reasonable person determines it to be an emergency, then it is deemed an emergency. In emergency care, it is the coding levels that often (i.e. level 4 vs level 5 claims), get disputed. This coupled with the Emergency Medical Treatment and Active Labor Act (EMTALA), providers are required to treat patients in emergency rooms for something that could very well present itself as a life threatening emergency, and in hindsight eventually may not turnout out be one.
- Site of Service - Hospitals are often more comprehensive places of care than clinics, and almost always more expensive. If a medical service that is provided in a more costly site of service, it is possible that the payer will dispute that.
- Enrollee Verification - Another common set of disputes are those regarding the enrollee's eligibility, hence the manner of how the eligibility was verified matters. If the medical service is listed in the contract it makes the verification process much cleaner, but if it is not it may be disputed.
Typically when a healthcare plan does not pay a bill it follows this path:
Steps to How Doctors and Healthcare Providers collect from Health Insurance Plans:
The steps are simple, but the time it takes is draining on any practice. group. Still none of it guarantees collecting the monies owed for healthcare providers. One simple way of improving the bottom line of a business is to improve the collections.
1) Follow-up on Your Accounts
The medical office and their staff ensure timely and accurate payments by monitoring status of claims and contacting the payers to identify the current status of the claim and determine if anything is preventing the payer from making a payment, and correcting issues.
2) Appeal The Claim Denials
The office staff conducts a review of all denied claims and undertake actions to secure payment if possible or recommend and complete adjustments on accounts as warranted.
3) Appeal Out of Network Claim Denials and Negotiate
It takes much more work to apply for collections and collect from out of network payers. Some businesses have inhouse staff expertise, with others don't. This is typically when a revenue cycle management company is very helpful, to help collect the "reasonable and customary" rates.
4) Understanding the Balances Owed to your Practice
Once all the efforts have been taken, i) collecting from insurance plans, ii) collection from out of network plans, iii) collecting from the patients directly; then a business must assess what is left over.
5) Next - The Ultimate CLEANUP - Litigation
Once the billing experts have done their part and the accountants are staring at large balances of uncollected receivables, then the glaring question is what do you do?
Solution to Collecting from Health Insurance Companies:
At Mirza Healthcare Law Partners, we go after the health insurance plans to collect those monies. We gather your data, summarize it, make demands on the insurance companies to pay; and if they don't, we sue them. Literally file a lawsuit! (some contracts require filing for arbitrations, but its a very similar process).
To Understand what to expect next, go to Hard to Collect Health Plans.
In the end, we go to bat for our healthcare providers, and we do it on a contingency fee basis - meaning if the client does not collect, we don't collect fees.