Handling Insurance and Reimbursement Difficulties
AT A GLANCE
- In order to survive, most eye care practices must participate with insurance plans.
- Successful negotiations require preparation and a respectful dialogue.
- One tip is to make clear the value that your practice brings to these insurance networks.
Medical insurance, health maintenance organizations, preferred provider organizations, exclusive provider organizations, point-of-service plans, high-deductible health plans, health savings accounts, vision insurance, discount plans—are you confused yet?
In order to see a patient in-network, you must be credentialed with each plan under each carrier. Each health plan has different copays, deductibles, and out-of-pocket maximums, making it difficult to know what a patient owes for the services provided. Moreover, it can be frustrating to receive an Explanation of Benefit (which is a denial), a reimbursement that is lower than expected, or to find out that the insurance carrier mailed the check to the patient instead of to your practice. The hours that your staff spends on hold or being transferred from one person to the next add to the frustration, and all of this raises one very big question: Why even take insurance? The answer lies in the numbers.
A NECESSARY EVIL
In 2019, the estimated US population was 330 million, 59 million of whom were covered by Medicare.1 According to the CDC, 12.1% of the US population 65 years of age and younger was uninsured in 2019.2 In other words, most potential patients have insurance and want to use it. In order to survive, most eye care practices must participate with insurance plans.
So, how do you work with insurance companies and handle the problems that arise? Following is some advice on navigating three of the most common issues that optometric practices face.
NO.1: TOO MANY PRACTICES ON THE PANEL IN MY AREA
One common issue keeping optometrists from getting credentialed for an insurance plan is too many local practices already on the panel. The COVID-19 pandemic is increasing the demand for health care. Contact network management through the insurance company and ask them to reconsider credentialing because of the current need.
Another worthwhile step is to send a letter appealing the decision. In it, state how you can benefit the panel. For example, if your practice offers extended office hours or weekend appointments, make that known to the insurance company. If you offer a niche service or have high credentials, let the insurance company know.
If your area is underserved, then the insurance company may see value in admitting your services. Do some research on your area and determine where you stand.
Reach out to your state association and/or society to find out if it can assist you or if there is a contact for the specific insurance company to whom you could appeal. Another option is to contact your State Department of Insurance (Insurance Commissioner).
NO. 2: REIMBURSEMENT SCHEDULES
It is possible to negotiate reimbursement schedules with insurance companies. Most practices will conquer the credentialing and start seeing patients as soon as possible at the reimbursement schedule that is offered in an initial contract. (Remember to read the entire contract from the insurance company before signing it.) This means having new patients receive treatment and services at potentially lower rates in the beginning.
Once your practice becomes established, it is time to review the initial contract’s reimbursement schedule. The cost of living increases each year. Why shouldn’t reimbursement increase as well? (Disclosure: I have negotiated with every health plan that I accept at my offices and have successfully renegotiated reimbursement with several of these plans.)
The first thing you need to know is the usual, customary, and reasonable (UCR) rate in your geographic area. This amount is paid for a medical service in a certain area based on what providers charge for the same or similar medical service. UCR charges are not regulated by state or federal agencies, but Medicare publishes its Medicare Allowable UCR fee schedule.
Contact network management to ask how to discuss a change to the reimbursement schedule. Some health plans require a written request, whereas others allow discussion over the phone.
Building a relationship and finding common ground with the payer set the stage for a productive conversation (see Communicating With Network Management). You must make clear the value that your practice brings to these insurance networks. An increase in reimbursement rates is not guaranteed, but success is more likely if you lay out your strategy ahead of time and support it with data. Can you document growth in the numbers of clinicians and of patients seen over time in your practice and an increase in claims from your practice? Can you speak knowledgeably about a shortage of eye care providers in your area? Does your practice offer services in multiple languages or offer extended hours?
Communicating With Network Management
A productive conversation means thinking about what you say and how you say it, and that begins with your opening statement.
Poor wording: “You need to pay me more because I am a better provider and have more demanding patients.”
Better wording: “My practice includes many patients with complex health problems who may benefit from some of the specialty care I offer.”
NO. 3: DENIALS OR CLAIMS NOT PAID CORRECTLY
Receiving an Explanation of Benefit can be frustrating. Payers assume, often correctly, that a practice cannot afford to have staff spend hours on the phone trying to resolve incorrect claims. Is it worth spending an hour to get the $20 owed on a claim?
Tackle one health plan at a time and have ready the appropriate information on all claims being asked about when an agent answers the phone. Document every phone call with the date and time, the customer service agent’s name and badge ID, the reference number for the call, and details of the call. Treat the agent with respect. Keep your cool and even establish a relationship with the agent so that you can reach out to him or her via email.
It is possible that the insurance company simply must reprocess the claim. Alternatively, it might have been billed incorrectly, and a corrected claim is required.
If your attempts to resolve the billing dispute or denied claim informally through phone calls or written letters fail, you will have to file a formal appeal with your health insurer. Every plan handles appeals differently, so it is important to learn the process for each plan.
DON’T GET OVERWHELMED
Dealing with insurance companies may seem like a daunting task. As my grandfather used to say, “The best way to eat an elephant is one bite at a time.” It helps to break the process down into small tasks.
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