Practice Management Alert

Tackle tough payment problems by knowing where to turn

You can file a complaint with the state insurance commissioner or the department of labor if you have a problem with a private payer. But who are the proper authorities to contact when you have a problem securing payment from Medicare, Medicaid and even a SNF? Here's what our experts advise:

Medicare and Medicaid:

-- If you receive a denial that you think is unfair, "There is a very well-defined administrative appeals process" to follow, says attorney Robert Wanerman with Reed Smith in Washington, D.C. The appeals process is in the manual from your Medicare carrier or Medicaid program.

For example, under the Medicare program, if you follow the appeals process correctly, meeting all the filing deadlines and other requirements, you could be eligible to advance up the appeals chain and present your claim before an administrative law judge, then the Medicare Appeals Council, and finally to a federal district court.

Most important: Educate yourself on the appeals process and use it to your advantage, Wanerman says.

-- If your claim is taking forever to be processed, you don't yet have access to this appeals process, Wanerman says. There has to be a decision made -- either a partial payment or flat-out denial -- before you can pursue an appeal.

While you wait: Contact your state medical association or your practice's national medical-specialty society to make them aware of the problem you're having with the processing of your claim, Wanerman says. These organizations are well positioned to tap into the source of the problem through  their extensive network of contacts and resources, he says. Chances are that other providers are having the same problem you are, and if a medical organization receives several complaints they are more likely to get involved, he adds.

Skilled Nursing Facilities:

The Medicare appeals process doesn't apply to payments you receive from a skilled nursing facility (SNF) under consolidated billing. Practitioners may have to deal directly with an SNF to resolve payment problems with an SNF, and any remedies will probably be based on the terms of a written agreement with the SNF, Wanerman says.  

Contracts are a must-have: Payment issues between SNFs and billing departments are governed by contracts between the two parties -- so make sure you use a contract for all SNF visits, he adds. You may be able to pursue SNF problems under state contract law, but you cannot use the Medicare or Medicaid appeals and complaint process, because your office is not the entity actually filing the claim.