Now that your paperwork is in order, you are ready to enter and conquer the world of Medicare and commercial insurances. Armed with a simple understanding of the process and with the right connections, any physician can become an expert in the insurance game.
All of the larger insurance plans, such as Blue Cross, Aetna, or United Healthcare will assign a provider representative that will cover your demographic area. Once you have become a provider that accepts reimbursement from an HMO, PPO, or other health plan, your first order of business is to find out the name and number for your provider rep; call and arrange a meeting.
Provider representatives for commercial insurers function in much the same way as a pharmaceutical salesperson. They are available to sell their product, monitor its use, handle patient complaints, and assure that physicians are honoring the terms of their contracts. They may also function as auditors and request annual or semi-annual examination of your charts and billing protocols for their members. During the course of these audits, they will also ascertain whether or not your office is in compliance with state safety and CLIA protocols, as well as your offices timely scheduling of appointments and return phone calls.
Physicians and administrators who show even the smallest shred of courtesy and interest in these overworked and often underpaid reps, are kept constantly aware of the changes in reimbursement and coding policies, upcoming seminars that may offer CME credits, and helpful suggestions for chart audit and patient monitoring. They will assist you in becoming an expert on navigating through their web-sites and some of them come complete with handfuls of goodies for patients and staff, such as pens key chains, coffee mugs and the like.
Representatives are also available to guide you through the application process and will often expedite your application and re-credentialing each year. So spending as little as 15 minutes with your provider representative can save you hours of time and grief.
At the beginning of your plan membership and each year that you continue to participate in an insurance plan, you should request the following from your representative:
Current Annual Fee Schedule
Requirements for timely filing of claims
Referral, testing and test site protocols
A user ID and password for using the insurance web-site
Handbook for participating providers ( check to make sure your listing
is correct)
Protocols for claims appeals
Name, address, and phone for the Medical Director of the plan
There may be times when a test or procedure is denied for medical necessity. In this case, you may have to contact the Medical Director of the plan and make an appeal based on necessity. Easy contact information for this agent will expedite the process.
Some doctors are interested in making a fee for service arrangements with one or more commercial plans. This means that the company will pay you a flat rate for each participating patient seen in your office. Your practice may be appealing to insurers for fee for service especially if you provide a specialty service that is not readily available in your demographic area and is covered under their plan.
You may pitch for this arrangement by mail to the Medical Director of the plan.
* Note of caution* Make sure you thoroughly research a fee for service arrangement before moving forward. Physicians who have arranged these so called "capitated" agreements can find themselves overwhelmed by the number of patients they are expected to treat or find that the reimbursement rate is not equal to the time it takes to service these patients. You may want to seek the advice of a health care attorney before finalizing any contract that involves fee for service.
Tomorrow : Universal Provider Datasource
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