Do Well Known Health Plans Such As: Sunshine Health, Wellcare, AMBetter, Florida Blue, Cigna, Humana, Magellan, Medicaid, Medicare, United Healthcare, Pay their Claims to Providers?
The answer is obviously, YES they do pay ALL of the "Clean Claim" submitted.
However, for healthcare offices and providers the financial struggle begins when they have submissions that are not deemed "clean claims" by the payers for no known reason, because they cannot fix the claim that is submitted.
There are things you can do to stay on top of your receivables. They include: training your staff, paying close attention to details when submitting claims, using technology to submit "clean claims", know your carriers and your your contracts even better, consider employing a billing revenue management company, and ultimately always have a reliable law firm that will help steer you clear and go after and collect what you are owed. We are a contingency legal fee law firm, if we don't collect for our clients we don't get paid.
Here are the things you can do if a claim gets denied:
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?
As a healthcare provider you have to be smart, you have to operate the business like an accountant and view the transactions that are denied with some skepticism.
Look for Warning Signs of Insolvency:
- Financial Losses
- Payment delays
- Blanket denials of categories of claims
- Sometimes they may deny every N(th) claim, meaning random denials without reason
- Other, there are other strategies that health plans use to deny claims.
If you are seeing inappropriate denials or delays in payment, then you should do the following:
- Review your termination provisions in the contract, and consider terminating the contract,
- Review the financial status of the health plan to see if you are detecting warning signs of a bankruptcy approaching,
- Be expedient in pursuing your claim and do not hesitate to go first, because you don't want to be the last one to collect from that payer,
- If the health plan files for bankruptcy, do pay attention to the bankruptcy notices and file your claim with the bankruptcy court.
If you are facing any of these issues, and you are not sure how to navigate them, call/text or email us and see what we can do for you. Most of our collection cases are handled on a contingency fee basis, so the legal fees is paid from the amounts collected.
Solution To Collecting From Health Insurance Companies:
At Mirza Healthcare Law Partners, we go after the health insurance plans to collect those monies on a contingency fee basis. 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).
Ben Mirza is not only an attorney but was formerly a CPA, with a masters of public health. There are over 100,000 attorneys in Florida, less than 500 of whom were ever Certified Public Accountants, and even less have the trifecta combination of law/finance/strategic healthcare background. The benefit of this combined and layered skillset works well for clients who want an advocate to approach the issues holistically.