How to handle problem payers


You’re doing all the right things with your claims: scrubbing them before submittal, filing them electronically within days of the service date, reviewing your EOBs and continually monitoring collections. Your claims operations are a well-oiled machine…except for one payer that’s gumming up the works.

If you’re dealing with a problem payer that’s ignoring claims, delaying payments, issuing unnecessary denials or underpaying on contracted rates, you need to take action.

So stand up for your practice! Arm yourself with the right data and address the situation assertively to keep from letting a payer push you around.

Prove it: Aggregate data for support

If you’re concerned about a certain payer after noticing a few closely timed underpayments (or other issues), it’s critical to back your suspicions with hard data. Review backlogs of your reports with an eye for the specific information you need.

“Go back a year or so and create a spreadsheet with pertinent information such as the patient name, the date they were seen, the codes you charged, what the insurance paid, the allowed amount, the date the insurance paid, if the patient had a portion to pay [co-insurance, co-pay, deductible] the contractual adjustment, and if there is a remaining balance,” advised blogger P.J. Cloud-Moulds in Physicians Practice. “Do this for at least a dozen patients. This will create a visual map for you to review.”

From that map, determine if your concerns are justified – or aren’t.

You may have originally thought that the payer was reimbursing your claims too slowly, but if the data shows that you’re being paid within the typical 90-day window -- even if it’s on day 89 -- you should probably hold off on taking your concerns to the insurance company until there’s more tangible proof.

Discuss it: Consult with your team on your findings

If the stats affirm your suspicions, save copies of your reports with the appropriate information highlighted and share it internally with all necessary interested parties.

It’s important to bounce your findings off at least one other individual with your practice’s best interests in mind, such as the physician most involved in business dealings, your head biller, or the contact at your medical billing service (who, if you’re outsourcing, should be highly involved in this process).

One or more of these individuals may have failed to inform you of details that explain the payer issues you’ve encountered. Perhaps the payer informed your head biller that technology troubles or upgrades caused some claims to be ignored accidentally, or that staffing issues incited a period of payment delays.

Consulting your colleagues provides an opportunity for explanations to come to light before any allegations of misconduct or poor performance are made. Once your team is briefed, take everyone’s knowledge of the situation into account as you decide on a course of action.

Act on it: Contact the payer and reach resolution

Ideally, your goal should be to resolve the situation, and the best way to do that is to straightforwardly present the troubling claims-data findings as a problem the insurer needs to solve.

Get on the phone with your closest contact or rep at the payer company. Lay out the recurring issue you’re facing in as much detail as possible -- the more stats you can relate, the more likely you are to reach favorable results.

“I have found that 90 percent of denials, improper payment amounts, delayed payment, etc. can be turned over by a simple (or not-so-simple) phone call,” said Cheryl Nash of American Physician Financial Solutions. “The reps at the payer are not as well-trained as we would like to think, but we are.”

Include particulars related to your contracts with the payer and make sure your concerns are escalated to a business manager who can monitor the situation moving forward.

When dealing with the payer, it’s important to act with your patients’ and practice’s best interests in mind. Avoid making threats of cutting off your acceptance of this insurer’s coverage unless you’re truly certain you’re willing to take your actions to that level.

If the payer insures a large portion of your patient base, it may hurt your business more to sever ties than to continue transacting as usual. Analyze your collections data thoroughly to elucidate the potential consequences of cutting them off before you make any comments of that nature.

Whether or not you’d be willing to no longer do business with your problem payer, it’s important that you approach them assertively and monitor their performance after voicing your concerns.

Your practice works hard to perform at a high level to ensure that both your patients and your bottom line thrive. In return, you shouldn’t be saddled with a payer who underperforms in their dealings with you.

How have you handled a “problem payer” situation at your practice?

Madelyn Young is a content writer for CareCloud who specializes in covering practice management, medical billing, HIPAA 5010, ICD-10 and revenue cycle management. You can read her work on Power Your Practice and the CareCloud Blog.