It’s a dilemma all too many offices face.

You submit your claims to the insurance company, Medicare or other third party payer and…you expect to be paid.

You check your mail, your clearinghouse submission file and perhaps even make a call to inquire about the status of your claim because the check simply has not arrived.

And here is where things get complicated and emotional.

In your eyes, the claim was sent and payment should be received. Period. End of story. In the eyes of the payer, the claim may have been received or it may qualify for reimbursement, but first, a few things need to be checked.

Meanwhile, you are still waiting for paycheck.  Yes, I used the term “paycheck” because that is exactly what each and every reimbursement represents: a portion of your paycheck and, for that matter, a portion of your staff’s paycheck as well.

And so, the battle is set in motion.  As you see it, your job is to submit a correct claim, in a timely manner and receive payment as quickly as possible. From the payer’s perspective, they need to verify the accuracy of benefit information, determine if the claim is free or errors and perhaps even request documentation – before they even consider paying your claim.

Time adds an interesting variable to the equation.  From your side of things, you have a time limit in which to file the claim and the payer has a time limit in which they must pay.  On the payer side, they are aware of the same two requirements, but they also factor in profitability which dictates that they cannot pay all claims at once, nor should they, because some claims are simply not-reimburseable.

Therefore, the payer has the added burden of factoring in legalized payment delays in the form of documentation requests and claims scrubbing that looks for basic errors in submission.  If the payer can catch either mistake on your part, they have a legitimate excuse not to pay.  Some payers also use questionable tactics to delay payments which range anywhere from stating that claims were lost in transit to downcoding (paying a lesser code than the one you submit).

For the naïve or newly initiated, this whole process can be extremely confusing, frustrating or downright pointless.  Even the most experienced billing staff or service has days when they question the logic of the entire system.  Alas, it is what it is.

While you probably cannot do much about the way that payers conduct their business, you certainly CAN try to control your side of the equation and tip the scales as much as possible in your favor. Whining and complaining about the unfairness of the system rarely produces any tangible improvements, although my email inbox is frequently filled with frustrated rants and raves about the inherent evils of the insurance game.

To this, I have two responses.  The first is my favorite line from motivational speaker, Les Brown, who states:  “Whoever told you life was fair?  You were misinformed!”  My second response is to advise all DC’s to not go into battle empty handed. Here are a few “weapons” I would recommend using:

1)      Prompt Pay Statutes. There are prompt payment laws in virtually every state.  If the insurance fails to pay in a timely manner, hold them to the fire.  They will do the same for you, if you fail to file your claim on time.  One note: most of these laws will support you, provided you have submitted a “clean” claim.  If your claim has errors and the payer delays or fails to pay, it’s your fault and the rules don’t apply. In fact, in June 2009 Medicare released an update that states that claims which do not meet basic legibility, format, or completion requirements are not considered as received for processing and may be rejected from the system.

2)      Electronic Format. If you are still submitting all claims on paper, you are worse than a plaid suit. Certainly wearing such a monster dates you as completely old school (as in old fart, not as in old skool retro cool). At least has the plaid suit has a chance to come back in style someday.  Your paper claims are just a testament to your inner dinosaur and about as efficient as the pony express. Electronic is faster on both ends – payment and submission – cheaper, and it allows to catch errors more quickly so you can turn them around for resubmission.

3)      Legibility. Don’t bother submitting documentation that is illegible unless you don’t mind working for free.  Virtually any EMR is superior to handwritten notes, if they are even borderline illegible.  Who defines legibility?  Unfortunately, it’s the guy on the other side of the fence who also determines whether you should be paid.  See above, for Medicare (and many other payers have similar policy language) if they can’t read it, you didn’t submit it.

4)      Appeals. Less than half of all claims are ever appealed.  Yet, most payers routinely reject 15-35% of all claims submitted. Some payers even randomly reject claims that may be perfectly payable, but you won’t get them to admit it.  Why would they do such a thing?  It’s good business (sort of).  The payers know that a percentage of your submissions will be eventually denied for errors and that you will never fix them or appeal.  If they deny them right off the bat, they have saved time and staff effort in actually performing a claims review.  And they know you won’t fight back.

5) Get Trained or Get Out of the Way. Far too many offices leave billing in the hands of amateurs.  For some, that may mean the doctor does the billing and we all know how well we were trained in chiropractic school for that purpose.  Other offices randomly hand over billing to the front desk person who may be qualified to answer the phone and greet patients, but is in no way ready to handle billing duties.  There’s a lot more to getting paid than collecting co-pays and verifying insurance (and unfortunately, not all offices are even doing that correctly).  In this arena, your best “weapon” may be brutal self-awareness.  Are you truly fit to train your staff?  Is your billing department well equipped to handle the duties? Are you willing to invest time and money into getting your staff trained and provided with proper resources to do their jobs?  If not, you should admit that you are in over your head and get help.  It was not the sling and the stone that led David to victory over Goliath, but divine intervention.  While I am not undermining the power of prayer, if your chief strategy when battling the insurance companies is to hope for a miracle, then perhaps it’s time you step aside, get out of the way, and outsource and/or get some experienced assistance for the ensuing conflict.

While I certainly don’t propose to have all the answers, I do have a few resources available for those who recognize the need for assistance:

  • Products. For those inexperienced in the art of appeals, it is an art form in that you need to know what to appeal and how. Most DC offices leave big bucks on the table, because they never bother to appeal anything.
  • Training. Per your request, this fall I am offering more webinars devoted to timely topics in the area of training you and your staff to get paid and keep out of trouble. If this particular article hit home, you should check out the upcoming webinar How to Oversee Your Chiropractic Billing Staff or Service” for more helpful hints of this nature. The webinar takes place on Thursday September 3, 2009 and will also be available on CD for those who can’t attend.  Check your email for more details.
  • Personalized Consulting. I can work one-on-one with your office (in a variety of formats) to help you improve your billing, coding, collections, documentation and ultimately help your office maximize reimbursements and minimize audit risk. Feel free to email me for more info.