Optometry Coding & Billing Alert

Problem payer won't communicate? Lean on your colleagues for support.

What if you take the recommended first three steps to deal with problem payers, but the payer still isn't responding or reimbursing you appropriately? Tap your peers and possibly even your state insurance commissioner.

In a previous Optometry Coding & Billing Alert, you learned about solving payer problems by researching policies, contacting payers, and refiling claims (see "Master the Art of Working With -- Or Around -- Problem Payers," in Vol. 7, No. 8).

If these tactics don't resolve the issues, move on to these additional tasks.

Talk to other practices in your geographical area and within the same specialty.

Find out if other practices are having similar issues and, if so, how they are dealing with them.

Here's how: Find out if others are experiencing similar problems with three tactics:

• Call the other practices in your area and other practices of the same specialty within your state. "When I see a trend, such as consistent underpays, or invalid place of service (POS) denials, I will contact other providers in the region to see if they are having the same problems," says Cheryl Nash, director of operations and senior account rep at American Physician Financial Solutions in Colorado Springs. "I have on numerous occasions detected a computer edit issue from an insurance company that can be corrected if you insist enough, and climb high enough, to make the payer investigate."

• Check your state optometric association's Web site for helpful resources.

• Join The Coding Institute's optometry billing listserv at www.coding911.com. Specialty-specific listservs often provide an opportunity to research if others are receiving the same types of denials, delays, or payment reductions.

Anyone who subscribes to the Optometry Coding & Billing Alert gets access an e-group where they can receive great help from billers and providers alike on a wealth of issues regarding coding and billing.

"We are all in this together and need to let the insurance companies know we will not take this lying down," agrees Gaye Pratt, coder/biller for Vincent P. Miraglia, MD, in Stuart, Fla.

If you attempt to resolve issues directly with a payer, but you don't seem to be getting anywhere, your final step should be to enlist the assistance of your state's medical society as well as involve your state's insurance commissioner, experts say.

Tap the medical society's power: Since single complaints here or there from a single practice have less impact with the state, the medical society has the ability to aggregate multiple problems from practices throughout the state. So, by involving your state's medical society and providing it with the data and problems you are experiencing with your payers, it can accumulate your data along with other practices' data and then report that aggregated data to the state department of insurance.

"If I don't receive a satisfactory answer, I inform them that I am sending a letter to the insurance commissioner that day," Pratt says.

Keep in mind: Contacting the insurance department in your state should be a last resort step as it can lead to animosity that is "not always productive when dealing with insurance companies you see on regular basis," Nash cautions. "I usually try to go to a provider advocate for grievances first and see if I can't find some resolution through that avenue."

Prolonged issues? If your practice seems to battle a particular payer over and over again, you might want to consider holding a meeting with the medical director for that payer and your physician to discuss the issues in dispute. If you cannot get the problem addressed and resolved, you may want to consider dropping that insurance company because your cost to collect a dollar is probably exceeding the payment of that dollar.

If your practice decides to no longer contract with a payer, be sure to check your contract and give the appropriate notice to the payer in terms of method (in writing) and sufficient notice as defined in the contract.

Then you want to make sure that you give sufficient notice to your patients. "When the patients complain to the insurance companies, I usually get very quick responses," Pratt adds.