Practice Management Alert

Question: Our physicians provided services to a patient after we verified her insurance eligibility, but the insurance company claims the patient is not covered. The employer group didn't pay the patient's premium, but the insurance company didn't have this information when we checked, probably because their rolls weren't up-to-date. Regardless, we're not getting paid. What should I do to make sure the physicians see payment?

New Jersey Subscriber

Answer: When insurance companies won't pay for patients no longer covered but verified at the time of service, it's game time. You can come out ahead if you finagle the company into complying to pay what it owes.

"I try to play a game with the insurance companies," says Victoria Jackson, administrator and chief executive officer of Southern Orange County Pediatric Associates in Southern California. Skillfully let insurers know that they're at fault, that their outdated information not your incorrect claim is the reason they have to pay for an uncovered patient.

Jackson says you should tell the insurer, "Gee, we provided the services to the patient based on your eligibility verification and the information we were given, and we certainly understand that something may have happened along the way, but ..." Fill in the blank with whatever applies. For example: "but you took six months to get your request in for money back for a patient no longer insured."

After shifting the blame, try to get the insurance company to get the money from the patient. "That's my first ploy," Jackson says, and a lot of times they'll do it, she adds. If you're dealing with managed care going through an IPA, assist them with the care of the IPA.

You can take it one step further by calling the employer group and finding out what happened, why the patient wasn't covered but has a card and eligibility that confirms coverage, Jackson says.

When you've dealing with the insurance of the employer, call the patient and give him a heads-up that there's a problem, Jackson says. Let the patient know that you're working on it, she adds. If the balance is higher, try to break the news by phone, she says.

But don't go to the patient first to get money; ask the insurance company to look to the patient. The insurance companies may in turn take the money owed out of your future payments for other patients. "It's a game, unfortunately," she reiterates, and if the insurance company doesn't pay, you're going to have to ask the patient for the money, she adds.

Regardless of who ends up paying, the name of the game is to make sure you're prepared to prove you're correct. "Make sure you've got your ducks in a row," Jackson says: You've done due diligence with the employer group to verify insurance information, and all of your information is correct.

You Be the Expert and Reader Questions contributed by Victoria Jackson, administrator and chief executive officer of Southern Orange County Pediatric Associates in Southern California in a recent The Coding Institute teleconference; and Jennifer Darling, compliance officer, insurance & collection specialist and owner of BBC Medical Management Services in Dallas. $ $ $