Never Give Up Constant battle with insurance companies

We are in a constant battle with insurance companies who will do anything to keep from paying a claim and then once they pay, it seems that they'll do anything to get the money back. Our job is to stop them. They have a contractual obligation to pay health benefits, which are paid for by the patient, member, employer or Government. For every attempt they make, they look for newer ways to threaten or intimidate the doctor into giving up.

Our doctors need to concentrate on treating their patients so these administrative issues need to be handled by us because that is our job. Giving up and caving in is easy to do but once we give up, the insurance companies win and like I said, they will come back with newer ways to come after you and the doctor. Like at the Alamo, we have to draw the line and fight back.

Now you may be in a location where your State regulatory agencies are as useful as a screen door on a submarine, but, if you meet a roadblock, you have to use innovative thinking to get around it. Again, you must never give up. Remember, the iron curtain was up for many decades but it did eventually fall. The Government created new laws to get the insurance companies to stop their games, but they (the insurance companies) have looked for loopholes to get around these laws. If Patient X has ABC Medicaid Insurance and ABC insurance hasn't paid the claim, you need to check your State laws to see what it says about claims payment. These laws may be the start of your fighting back foundation. Anytime you fight back, you must make sure you are 5,000% correct. You must be impeachable! You verify that the patient had the benefit or was eligible for the medical care and that the benefit is a covered service.

However, you must not do anything blind! VERIFY, VERIFY, VERIFY are not just words, they should be your mantra as they are a huge part of your business. You don't deal with the monkey; you deal with the organ grinder. Now I cannot tell you how many times I've heard "I appealed and never heard back" or "When I checked, I was told they never got it". Why did you never hear back? Why didn't they get it? It may be because you sent the appeal to customer service or to the claims address. Your appeal arrived and it somehow found its way into the trashcan. Perhaps you didn't send it Certified Mail/Return Receipt, so now you have no proof of what you did or what you say. To prevent your work from being filed in the circular filing cabinet (i.e. trash can), you must send everything by Certified Mail/Return Receipt. You cannot afford not to.

Now the burden of proof is on YOU to prove you did what you said you did. Personally, I never send any appeal or rebuttal to customer service or the claims address. I go to the top by going to the CEO or President of the company and get them involved. It's easier trying to get something down by letting it trickle down rather than trying to make it trickle up! But if you get no response, then try your regulatory agency that regulates the insurance benefits. For example, if I send a grievance to the State Medicaid regulatory agency, it too is sent by certified Mail/return receipt. A copy of my grievance is also sent to the insurance company CEO and the patient (of course, you guessed it - certified Mail/return receipt. This way the patient can become aware of what their insurance company is doing. Like the CEO of the insurance company, I send my correspondence to the director of the regulatory agency. Always go to the top of the food chain. If you don't get any answers or help from your State agency, go higher. Send a complaint to the Governor of your State with a courtesy copy to the regulatory agency director. Now they have to answer to the head government official for your State. Again, you send copies to the insurance company CEO and patient. I prefer to keep everyone in the loop and informed. If the Governor is also ineffective, contact your State Congress by writing to the head of the committee on healthcare affairs. If your State appears to be ineffective, you should go higher! For Medicare and Medicaid, contact the Director of the Centers for Medicare and Medicaid services in Washington DC and the Secretary for Health and Human Services. Keep all your correspondence 1,000% professional, stick to the facts and refer to your supporting documentation, which should be always HIPAA privacy sanitized. Doing things right can get someone to respond to you.

If none of this works, try contacting your local and national news organizations. No one wants to see these things on TV or in the newspapers, especially governmental representatives who wish to become reelected, but you must allow them the chance to respond. The final step may be with the decision of the doctor to take this to court using the services of an experienced health care lawyer. Again, you must never give up. That is what the insurance company banks on, and you must make sure you did everything correct so that nothing can come back to haunt you. This business demands a Grizzly Bear attitude. And remember the golden rule with a Grizzly Bear, YOU NEVER POKE THE BEAR!

Steven M. Verno, CMBS, CEMCS, CMSCS, Professor, Medical Coding and Billing Instruction at Florida Metropolitan University. Director of Reimbursement, Coding and Billing Training and Consultant with Emergency Medicine Specialists.