Claims denials from health insurance companies have spawned a growing industry:
“The insurers outcode us, they outsmart us and they have more manpower,” says Shari Reynolds, the administrator at Paluxy Valley, which pays athenahealth a little over 3% of the $2.5 million it collects annually from insurers. “Now at least we have a fighting chance.”Doctors increasingly complain that the insurance industry uses complex, opaque claims systems to confound their efforts to get paid fairly for their work. Insurers say their systems are designed to counter unnecessary charges and help keep down soaring health-care costs. Like many tug-of-wars over the health-care money pot, the tension has spawned a booming industry of intermediaries.
It’s called “denial management.” Doctors, clinics and hospitals are investing in software systems costing them each hundreds of thousands of dollars to help them navigate insurers’ systems and head off denials. They’re also hiring legions of firms that dig through past claims in search of shortchanged payments and tussle with insurers over rejected charges. “Turn denials into dollars,” promises one consultant’s online advertisement.
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{ 13 comments }
That’s what I do. In addition to the Medicare compliance product my company offers, we also do denial management. We will call the insurance medical directors while the patient is still in the hospital to fight the denial concurrently but also we obtain the chart and write letters for retrospective appeals.
We are growing by leaps and bounds. Anyone want a non-clinical job?
Dr. Steve
I can’t believe the insurance industry that you all went to bat for on tort reform isn’t acting appropriately!?!?!
Perhaps you should hire lawyers to sue them, you know how insurers just roll over on any old case once you file suit. Better hurry, before those insurers turn on you greedy doctors and get themselves some tort reform on you.
When my insurance company denies a claim to my doctor I personally get on the phone with the insurance company and make sure they pay it. Sometimes it takes 15 minutes. Sometimes it takes multiple calls that can last an hour or more. One doctor’s office was amazed that I did this “for them”. I am amazed that it isn’t a daily occurance. It’s my bill. It makes sense to me that I have to get it paid. If I have insurance that covers the service, it is my responsibility to fix the problem with them. I don’t understand why my doctor should have to pay anyone (his own staff or another company) to do so.
I can imagine that if I were in an ICU on a ventilator that this wouldn’t work so obviously it isn’t practical for every case but really, even folks in that ICU usually have a family member directing their healthcare decisions. That person should do the dirty work.
It isn’t that hard to do. The way I make it work includes three facts. 1) I know what my policy covers so the insurance company can’t give me the run around. 2) I am the customer. The insurance company wants my premiums. Just like any consumer problem, moving up the line from the person who answers the phone to their supervisor and the supervisor’s supervisor will eventually get the problem fixed. 3) I have employer based insurance. If all else fails, I go to my benefits manager and they end up on the phone with their contact at the insurance company. The employer is the BIG consumer in the equation and they ALWAYS get what they want.
“I can’t believe the insurance industry that you all went to bat for on tort reform isn’t acting appropriately!?!?!”
CJD, you are so tiresome. Physicians have not “gone to bat” for the insurance companies. We have to go to bat against many enemies, including the insurance companies, and ATLA
Wow, a patient that sees the Doctor’s bill as HER bill!!! Please have more children and contribute to an increase in the “personal responsiblity ” gene.
Doc’s-Have you ever thought of informing your patients that you no longer take insurance? Let the patients deal with getting reimbursed.
Now *that* is bureaucracy!
Much simpler when the government gets the bill. There’s no arguing, no delay in payment(otherwise interest is collected).
“Much simpler when the government gets the bill. “
You might think so but no. Medicare has taken several steps in recent years to lower payments to hospital (observation status and transfer DRGs). And they do retroactively deny payment.
Medicare where? there are lots of places with “medicare”.
I do some UM work–yes, denying doctors. With one hosptial chain I deal with they outsource appeals to another company.
So this MD medical bureaucrat gets to talk to another MD medical bureaucrat about whether the third MD treating the patient gets paid his inadquate sub-market government dictated payment rate for services that he has already delivered. The beauty of is that the two of us who are not treating the patient are working for wage rates that we negotiated and freely agreed to–unlike the poor guy doing the treatment.
Isn’t managed care wonderful! I guess it helps solve the physician surplus problem.
Oh, by the way, this IS for a government program. So much for “single payer” uptopia fantasies.
“CJD, you are so tiresome. Physicians have not “gone to bat” for the insurance companies. We have to go to bat against many enemies, including the insurance companies, and ATLA”
Whatever you need to tell yourself to sleep at night. It’s all the same right? Insurers actually win, you think you win, lawyers make just as much money working for the defense against you ultimately, and oh yeah, the patients (you remember them, right?) lose.
Must get a job , CJD
Must stop being jealous of other people’s free time Anon.
Doctors cannot win the fight with insurers over denied payments. Insurers already have their money…they will do everything they can – lie, cheat, whatever – to keep it.
The best denial management physicians can employ is to deny contracting with third party payers altogether. Just say “no” to them…throw their contracts in the trash.
As a primary care physician who as not accepted insurance for over six years, I receive payment directly from patients at the time of service. If a patient denies me payment, I deny him service from that point forward (that’s not the type of patient I want in my practice anyway – and with over 7000 patients I can’t afford spending any time with patients who are not willing to pay my reasonable fees – usually $40 to $60).
Because I refuse third party payment, I have one-third the overhead and one-third the employees of most primary care physicians (and 1/100th of the headaches).
Americans neither need nor can afford third party payment for routine medical care.
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