Stake your claim: How to fight for fair reimbursement

Managed care companies don't exactly go out of their way to make the claims submission process as easy and transparent as possible.

There have been many cases of outright downcoding and intentional underpayments by plans, but often the problem with getting paid is that physicians are too enveloped in the fog of health plan gobbledygook and bureaucracy to fight for their fair reimbursement. The Advisory Board Co., a health, membership and research organization, estimates that 90% of claim denials are preventable and 67% of denials are recoverable. Based on those estimates, physicians collectively lose billions of dollars a year of revenue that is rightfully theirs.

The American Medical Association is offering help for physicians to cut through the health plan fog with its "Claims Management Resource Kit." It is an easy-to-use guide to preparing claims, following their progress and appealing them when necessary. The guide is offered at no charge, exclusively to AMA member physicians.

Consultants are quick to tell physicians that auditing their claims and taking other steps to fight against downcoding and bundling are essential tools for a practice. But putting together a system to check on insurers may seem like an overwhelming administrative hassle.

Using the AMA's kit gives physicians a huge assist in that process, making a daunting task easier to approach and manage.

The kit contains three booklets:

• "Prepare That Claim" is designed to help you and your practice review your claims-management process. It includes sample workflows for patient registration, clinical documentation, patient check-out, coding, billing and collection. It also includes sample forms to help physicians work efficiently and effectively in preparing, submitting and collecting claims.
• "Follow That Claim" is a look at how health plans process claims, both electronic and paper. It includes flow charts and tables detailing how plans typically handle their internal and external claims processing, adjudications and payments. This information can help physicians better understand and comply with health plan policies, thereby assisting in receiving timely and complete payment.
• "Appeal That Claim" offers charts, tips and advice for setting up an internal claims-auditing system, which is key to knowing what claims should be appealed. The booklet helps physicians and staff reduce their administrative burden, yet gain greater awareness of how and when to appeal an underpaid, delayed or inappropriately denied claim.

The kit also includes a CD with forms, sample letters and other tools to help improve the claims-management process, as well as a wall chart to help track a claim's submission, processing and payment path.

Even non-member physicians can take a valuable message just from the description of the kit: In order to ensure you're getting paid fairly, you must approach your claims management in an organized, systematic way.

Key to getting paid what you deserve is knowing what exactly you should be getting paid.

Insurers, as it has been long documented, are not always up-front with information about reimbursements. Until they are, it's in a physician's best interest to know what a fair reimbursement is, to be able to document it and to effectively follow through on getting the full amount. The less time spent in hassles over what the doctor is supposed to be paid can then be spent on what the doctor is really supposed to do, take care of patients.