Practice Management Alert

Hint: Refusing underpayments is a great way to get what you deserve

When you play nice with a non-contracted carrier and it still refuses to pay, you need to take out the big guns.

There are some lesser-known ways of convincing non-contracted carriers to pay, says Steve Verno, NREMTP, CMBSI, director of reimbursement at Emergency Medicine Specialists in Hollywood, Fla. If you're tired of talking in circles with a payer, try one of these tricks - both of which have worked well for Verno in the past.

1. Send back an underpaid claim.

If you receive an underpayment from a non-contracted carrier, "don't post the payment to the account at all,"  Verno says. Instead, "send the entire check back to the carrier" with a letter stating the following: 

1. Our practice is not contracted with you,

2. We are entitled to the full charges on this claim,

3. You paid us less than the full amount, so we're not accepting this check, and

4. If you don't pay us the full amount within 30 days, we will balance bill your member (the patient) for the total.

Success: When Verno and his colleagues have tried this, carriers have often sent a check for the full amount within 40 days. This tactic "won't work all the time," Verno says, but it's certainly worth a try.

2. Refuse to submit future claims.

"If you're non-contracted with a carrier, with the exception of Medicare and Medicaid, you're not obligated to send a claim at all," Verno says. So when a non-contracted carrier refuses to resolve your outstanding claims, respond that in the future you won't bother even submitting claims for its members - you'll just balance bill the patients from the beginning.

Hold your ground: Most likely the carrier will threaten that you have to submit a claim, but stick to your guns, Verno says. Ask the carrier to point to a law that says you're legally obligated to submit a claim. If you're non-contracted, the only legal contract is between the carrier and the patient - and the patient is responsible for submitting claims.

Next step: When you balance bill the patient, the patient will in turn submit the bill to the carrier, and the carrier may send your practice a request for a copy of the claim. The best way to handle this situation is to tell the carrier, "I'm not getting involved in the contract between you and your member," Verno says. You're not obligated to send a copy of the claim form, so tell the carrier to ask its member for the document.

Don't be fooled: After you've turned the carrier away, the patient will likely contact your billing office complaining his insurance company won't pay the bill until you send a copy of the claim form. But if you provide a copy of the claim form and the carrier pays the member, you have no guarantee that the patient will in turn pay you, Verno says.

Do this: You should insist that the patient pay you first, and then you will provide the patient with a copy of the claim form. The patient can then receive reimbursement from the carrier, and all parties will be happy, he says.