Playing the Claims Game (cont.)
Inconsistencies in the system
And that’s where the crux of the
problem lies. The Centers for Medicare and Medicaid have
established specific codes and modifiers which physicians are
required to use when documenting services rendered. Private
insurance companies are not required to use these same codes
and/or modifiers and many do not. Therefore, a physician must
be familiar with the coding system used by each insurance
carrier. These codes and definitions can change at any time
without notice. “I deal with 40 different insurance
companies,” says Swensson. “There’s no way I
can keep up with all of their rules and changes.”
Claims can be rejected
for any number of reasons. Some of the most common include:
incorrect codes for the procedure submitted, incorrect
modifiers, lack of proper information, the procedure not being
considered a medical necessity or not warranting additional
medical expertise. Depending on the insurance carrier, the
reason for rejection may or may not be included in the
explanation of benefits (EOB) sent to the physician. It’s
up to the physician or her staff to track the claim down,
contact the carrier, and find the reason for rejection. Of
course, then it must be resubmitted, often with additional
supporting documentation. “We can spend as long as six
months or more trying to get payment for a bill,” says
Swensson. Two years after leaving private practice, Steele says
he still has $10,000 in outstanding claims.
In addition to
documentation headaches, there are inconsistencies in what
insurance companies will pay for. “Sometimes [a company]
will pay for a procedure and sometimes they won’t pay
[for the identical procedure],” says Baltz.
“It’s up to us to find out why. If we don’t
ask the right question in the right way, we’re not given
the right answer.”
Two sides of the coin
Mohit Ghose, the director of public affairs
with America’s Health Insurance Plans in Washington, DC, which represents 1,300
insurers and health plans nationwide, says the payment process
is problematic for both sides. “The laws are extremely
tight,” he says. “Ninety-five percent of laws
require plans to pay in a 35- to 45-day timeframe from the day
the patient receives the service. However, there is no prompt
filing component. If we don’t receive the claim until day
20, we still have to work within that same time frame.”
Swensson disputes this
fact, claiming that in most states, the time requirement begins
when the insurance company records it has received the claim.
In fact, most state laws say the clock starts ticking upon
mailing/e-mailing or receipt of the claim.
Ghose also disputes the
claims denial rate physicians report. “In 1997, the
ultimate denial rate for preauthorized claims was 1.4
percent,” he says. However, these were for hospital
claims, an apples and oranges comparison with denial rates for
physician offices tending to run higher, according to Swensson,
who says hospitals carry more clout because of their higher
dollar claims. Multiple attempts to get denial rates for
outpatient physician visits were unsuccessful.
“The insurance
industry has a two-fold responsibility, “says Ghose.
“We have to ensure physicians are being paid for their
services at the proper rate in a timely fashion. Secondly, from
the employer perspective, insurance companies have to ensure
they are paying only claims that fall within that contract, and
that has been an abuse in the past.”
“We’re not
here to hold onto money,” he says. “We have to
strike a balance between paying correctly for the right
services, for the right contract, and to prevent fraud.”
There are scattered efforts
to make improvements in the system. The Council for
Affordable Quality Healthcare,
(CAQH), a not-for-profit alliance of the major health plans and
networks, was created in 1999 by a coalition of health- plan
CEOs to reduce administrative barriers to claims processing. It
has developed a universal credentialing data source program
that eliminates the need for doctors to complete multiple
credentialing forms.
Electronic claims processing
Electronic claims processing, which many
offices now use, is intended to improve the claims filing
process, but it’s already receiving mixed reviews. New
HIPAA guidelines originally required all physician offices and
third party payers to have electronic claims processing in
place by October, 2003. However, that deadline has been
forgiven and all offices are now expected to at least have a
plan in place to institute electronic claims processing.
“There are still
pockets of the country that are not using standardized formats,
but once providers and third-party claims administrators are
all on the same page, things should get much better,”
says Ghose. “For instance, if a claim isn’t clean,
it can be sent back to the provider within 72 hours.”
However, some providers
who are using electronic claims processing say the system has
its own set of problems. For starters, insurance carriers may
use two to three different billing software clearinghouses that
sometimes don’t speak the same language. That can result
in lost or rejected claims. Secondly, insurance carriers bill
the health-care provider a transaction fee for use of the
clearinghouse, further reducing the physician’s payment
for the service being billed.
“Electronic
claims have not necessarily had an impact on the claims
process,” says Rohack. “The only difference is that
now we get rejected claims faster.” Many states,
especially those that differentiate between electronic and
manual claims processing, require payment within 15 to 20 days
for claims submitted electronically.
In the end, change is coming
slowly, Rohack says. The AMA and state medical associations are
slowly making changes to the system, and “insurers are
beginning to recognize that physicians play a very important
role in providing high quality medical care,” he says.
However, he cautions physicians to stand up for quality care by
communicating to patients their dissatisfaction with particular
insurance plans. “Eventually these insurers will begin to
lose customers.” g
.
1 | 2
