Provider Office Myths vs. Payer Realities
Tressa Harley
Payer Relations Expert | Healthcare Consultant | Strategist | Coach Helping Healthcare Administrators Maximize Health Insurance Reimbursement
Ever wonder why it’s such a challenge for medical practices to get direct answers from health insurers?
Part of the reason for that is because many of the conversations begin with beliefs and expectations that aren’t realistic.
Understanding what to ask and who to ask is the ticket to saving time and sanity when reconciling denials.
Myth #1 - They make it hard for you to get your money on purpose
Reality - There is no one person or department at any health insurance company that is looking at your claims patterns, contract, or taking inventory of your reported concerns, in an effort to make sure that your practice is taking advantage of every opportunity.
Instead, the payer is fielding your calls and responding to the question you’re asking, in the moment. They are not responding to your question from the big picture perspective of maximizing reimbursement. You have to step into that role.
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Myth #2 - Reps are told to deny services and say no, even though they know the answer
Reality - First, customer service and network reps do not have the authority to outright deny or approve services. Additionally, they aren’t trained by their respective payer to code claims. So unless the rep brought previous experience from another company, they don’t actually know what modifier or service code(s) would allow a service to pay. However, they are equipped to investigate if the payer’s system processed the claim correctly. Which is why it’s important to ask the question according to the rep’s knowledge base and resources.?
Myth #3 - If you keep calling you’ll eventually get the “right” answer?
Reality - Maybe…maybe not. Once you start shopping around for answers, you’re actually making the entire process more difficult. Internally, areas are hesitant to touch a situation with a long list of documented exchanges and are extremely cautious to override a previous decision. To get the right answer, it’s paramount to craft the question with specifics & direct it to the appropriate area, the first time.
Let’s turn these misconceptions (and others) into clear, effective conversations, MDOfficeInsights.com.
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6 个月"Which is why it’s important to ask the question according to the rep’s knowledge base and resources." Here's the problem with that. What if the rep has no knowledge base? And what if they have no resources into the systems they need to access to solve your problem? And what if they're not able to transfer you back onshore? That's what people run into these days. It's not offshoring per se, but there's a big difference between being fluent in conversational English and being able to manage technical conversations about insurance claims. I'm frequently told things by representatives that I know, after 26 years in this business, to be false. They aren't deliberately lying, I know that. But all the same, they are obstructions. For all the wonderful technology that we have today, the inability to pick up the phone and speak with somebody who knows their job is responsible for a lot of the frustrations in billing today. And it's not even just billing. When was the last time you called an airline? Or the cable company? Any call center that prioritizes the number of completed calls and speed of "answering" questions by definition is not customer service.
CMRS ( Certified Medical Reimbursement Specialist) Owner, CMT Consulting LLC
6 个月Very well put and thoughtful.