Opinion

Stake your claim for accurate reimbursement

An AMA initiative is designed to provide doctors the tools to appeal inappropriately denied and underpaid insurance claims.

Posted Oct. 20, 2008.

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One of the biggest and inexcusably wasteful burdens on the health care system comes after treatment is delivered.

The cost of inefficient payment claims processing has been pegged at anywhere from $21 billion to $210 billion annually, according to a recent report by a top accounting firm. Those are numbers almost too big to imagine but all too real to physicians. Research shows that doctors are forced to spend up to 14% of total practice revenue simply to ensure that they are paid accurately for the services provided.

Earlier this year, the American Medical Association focused attention on this problem, one that is rarely addressed in discussions on health system reform. Next month the AMA will launch a push to get physicians the necessary tools so they can take direct action to get paid properly.

In June, the AMA issued its first National Health Insurer Report Card on claims processing and found that insurers' claim payments often are inaccurate and late, while denial explanations are inconsistent. When it unveiled the report at its Annual Meeting, the AMA launched the "Heal the Claims Process" campaign to fix the claims-payment system.

As part of the initiative, the AMA has dubbed November "Heal that Claim" month and is urging physicians to take action to receive what's rightfully theirs in the claims process. Under the AMA's prescription, doctors can help mend the system by reviewing their claims-filing practices to ensure accurate and timely submissions to the appropriate payer. Doctors also should review claims for payment accuracy and appeal inappropriately underpaid or denied claims.

November is the right time for doctors to take stock. During the last quarter of the year, many practices see an increase in claim denials from insurers, the AMA notes.

The Association has equipped physicians with the appropriate tools to monitor their claims by creating online resources through its Practice Management Center (link).

The tools, which are free to all physicians, enable doctors and their staffs to prepare claims, track the progress of claims and, when necessary, appeal a claim.

On the Web site, "Prepare that Claim" materials address clinical documentation, coding, billing and collection and offer sample forms designed to help doctors efficiently prepare, submit and collect claims. The "Follow that Claim" section examines how health insurers process electronic and paper claims and gives information on understanding and complying with health plan policies. "Appeal that Claim" provides advice on creating an internal claims-auditing system.

Even with these important resources, doctors certainly cannot heal the process alone.

The third-party payers who did so much to create this mess can improve the situation by giving full transparency to medical payment policies, fee schedules and other data. They can pay promptly and accurately the first time claims are submitted, and implement Health Insurance Portability and Accountability Act electronic standard transactions.

November's "Heal that Claim" month is a perfect opportunity for physicians to take action and get the accurate and timely payments that they deserve. A healed claims process will provide savings -- the AMA hopes to reduce the administrative costs of processing claims from 14% to 1% of a physician's total revenue -- and allow doctors to crawl out from under a process that is burdensome and detracts from caring for patients.

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