Podiatry Coding & Billing Alert

What if you take the recommended first two 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 last month's Podiatry Coding & Billing Alert, you learned about solving payer problems by researching policies and contacting payers (see "Master the Art of Working With -- Or Around --Problem Payers," Vol.1, No. 3). If these tactics don't resolve the issues, move on to these additional tasks.

Whether the issue is a payment delay or an improper denial, you will likely want to refile your claim. For a payment delay, resend your claim and include a letter explaining when you sent the first claim and telling the payer you expect timely payment. You can also include a proof of timely filing from your clearinghouse. You should be receiving a report from your clearinghouse confirming receipt of the claim by the payer. This report is called a 997 Acknowledgement of Receipt.

"My first step is to send a second claim with the notation that I will report untimely claim payments to the state insurance commissioner," says Gaye Pratt, coder/biller for Dr. Vincent P. Miraglia in Stuart, Fla. "Usually this works."

If you're appealing a denial, follow these steps:

• Identify the incorrect processing so you can appeal the incorrect or non-payment

• Pull any supporting documentation (the original patient chart, notes regarding the treatment and medical ecessity, etc.).

• Call the payer to verify whether you can refile the claim by phone or fax or if you need to mail a hard copy with a written appeal and the documentation to the carrier.

• If the payer does not accept appeals by phone or fax, mail in the documentation with an appeal letter. Include a copy of the original claim and the EOB (remittance advice) that shows the incorrect reimbursement, along with a cover letter explaining why the insurer should reimburse the claim differently.

• If you refile the claim by phone or fax, expect the carrier to take about 10 days before responding; allow a month for responses to appeals you mail. Once that time period has passed, begin following up until the payer responds.

Caveat: You should not automatically submit identical, duplicate claims to payers when you don't think you're getting payment in a timely fashion. Duplicate billing tops most payers' lists of billing errors. Some insurance companies, including Medicare, consider duplicate billing worthy of fraud investigation.

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 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 medical society's Web site for helpful resources.

• Join The Coding Institute's 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. "We are all in this together and need to let the insurance companies know we will not take this laying own," Pratt agrees.

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.

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 them with the data and problems you are experiencing with your payers, they 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 indispute. 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.