An unfortunate sign of the times in our present health care mess is the ever-increasing tendency for insurance companies to discover new and creative strategies to avoid paying your claims or minimize reimbursements on the ones they do pay.
For example, most offices would probably be acutely aware that a payer failed to reimburse them for anything over the past several months. Zero is an easy number to spot and no matter how poor our practice management reporting is, you will likely catch this (eventually).What's not so simple is keeping up with the myriad of moving targets that payers keep shifting around us.
In our defense, we've got better things to do: patients to see, staff to manage and, oh yes, a business to run. So, while you may identify a big, fat, hairy monster of a goose-egg as a potential problem, your standard operating procedures may no longer be sufficient to spot the subtle sabotage being waged against you.
Time Have Changed; New Strategies Needed
In short: Times have changed and we must adapt to navigate the narrow waters toward getting paid. One often-overlooked and vital tool to accomplish this is your insurance verification procedures. In day past, it was simple enough to call the insurance company and make sure your patient had coverage. "Advanced" offices systematized this process and utilized a verification form for this purpose. These days, verification of benefits is not so cut and dry. As such, it may be time to enhance your strategies to ensure that emerging claims processing tactics aimed at reducing or eliminating payments are identified and thwarted.
Unfortunately, most chiropractic offices are employing few, if any, of these tactics. Instead, they are doing insurance verification "the way we have always done it" and getting the same (or worse) results. Other offices have given up entirely.
Insurance Hazards to Avoid
To truly maximize your patient's chiropractic benefits (and your reimbursements), here a few verification hazards you definitely want to avoid:
Pay-the-Patient Problems: If you are a non-participating provider for plans, you may have realized that carriers are testing "direct patient initiatives" (also known as "pay-the-patient"). The concept is simple: Insurance payers want you to be in their network, so they will make it very inconvenient for those who are not by paying the patient instead of the doctor – regardless of how your claim form is completed.
Few payers will volunteer this information, so, once again, you must ask. Specifically, ask if the assignment of benefits will be honored. If the payer will not honor the assignment, request that the anti-assignment clause be faxed to you for your records. Insurance carriers may balk at providing such information. However, if you put your demand in writing, the payer may be obligated to respond in compliance with potentially applicable state and federal disclosure laws.
If a payer refuses to disclose if they have such a policy or fax you a copy, consider this a warning that you may not get paid. Instead, you may have to chase your patient for balances due and lose profitability in the process – unless you are prepared.
Fee Schedule Fiascos: To providers, the concept is straightforward: We render services, bill for them and expect to be paid. Things start to get fuzzy, however, when we try to determine exactly how much the reimbursement will be. Because benefits vary greatly from policy to policy, it is important to seek an actual "quote" regarding the specific contracted or reimbursement rate we will be paid.
If the carrier states that such information is not available prior to receipt of the bill, put the request in writing and submit it with a copy of the assignment of benefits. Again, federal and state disclosure laws may subject payers to providing such specifics upon written request – but, as you've likely guessed, payers will never freely volunteer that information.
Double Co-Pay Disasters: An insurance tactic waged specifically against chiropractors that is becoming more common is what I refer to as the "double co-pay disaster." Some (but not all) plans have decided to charge separate co-pays (and/or count separate visits) for extremity adjustments (98943) when performed on the same day as a spinal adjustment (98940-98942). Other payers do this for rehabilitative procedures such as massage, exercise, traction or other forms of therapy.
To avoid this surprise (for your and the patient's benefit), you must perform your due diligence during the verification process and find this out beforehand. How? Simple: Ask specific questions to get the right answers!
Deductible Disclosures, Calculations and Carryovers: Most verification forms include a blank where your CA writes in the amount of the deductible. In the old days, this was enough. Today, a number of follow-up questions may be necessary due to the emergence of "creative" deductible calculation scenarios. For example, some companies have different policies on exactly which services go toward meeting the deductible and which do not. In addition, you need to find out how much of the deductible has been used and if the yearly calculation will carry over any previous year expenditures. Finally, don't simply assume you are on a calendar year plan; it could cost you and your patient.
Utilization Review Abuse: Although utilization review is not part of the verification process, taking a proactive step can help you prevent future denial or appeal nightmares. This step is particularly handy for payers who are "trigger happy" with their utilization review procedures and tend to cut off your care after a generous 2-3 visits, despite what the patient's benefits may indicate.
Fortunately, there are standards for how and when payers can perform utilization review. If the carrier is accredited by the Utilization Review Accredited Commission (and most large payers are), it will have to follow strict procedures designed to maintain accountability of the utilization review process. For example, URAC-accredited payers must provide certain information, such as credentials of the reviewer and clinical review criteria, upon request. If the payer (or utilization review company) is unaccredited, this may be a red flag. If it is URAC accredited, you can hold them accountable to administer your claims in a proper fashion. For more information about URAC accreditation and how it may benefit you and your patients, see www.urac.org.
Verification Call Copouts: Anyone who has ever verified benefits is familiar with the phrase, "Verification is not a guarantee of payment." While that sounds like a complete copout on the part of the insurance company, you still have to do your part to meet medical necessity, properly bill, code and document your services. On the other hand, you still have legal appeal rights if the payer misrepresents benefits.
To strengthen your position, it is possible to submit a written request to establish a right to benefit disclosure. By having a quick template letter to use, you may have firmer grounds for pursuing legal action based on misrepresentation of benefits and/or failure to properly disclose benefit information.
Raising the Bar
If you have not been using the above six steps in your verification-of-benefits procedures, be assured that you are not alone. However, as stated above, we cannot continue to operate our practices in the same manner we did in 1985. Insurance companies are much more savvy these days in their denial structures and in creating hoops you must jump through to get paid. Consequently, we must raise the bar on our end as well by collecting better information as part of our verifications, demanding appropriate disclosures and (if applicable), smelling trouble before we step in it.
You may want to share this information with your staff and develop new strategies to verify benefits which implement this material into your routine procedures. For those of you who don't wish to re-invent the wheel, I would be happy to provide you with a free copy of our newly designed insurance verification form, which incorporates the steps above. Just send me an e-mail at
, noting that you read this article in DC.
Now that you're aware of some of the new tactics being employed against you, stay one step ahead of the curve so you can be paid for the good work that you do!
Dr. Tom Necela maintains a private practice in Washington state. He is also the founder of The Strategic Chiropractor, a consulting firm for chiropractors. Dr. Necela can be contacted with questions or comments via his Web site, www.strategicdc.com.