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Navigating the Insurance System

By Joan Zallee, Retired Business Manager, RN

When you open up your letter from the insurance company, the column “Amount Paid” can be downright stressful. How do you navigate the business of the wonderful insurance companies so that the number in this column is larger and paid more quickly? That is what this article is all about.

Beyond the adjusted rates your institution has negotiated there are steps you can take to make the process and experience less miserable, and even more helpful. I do recommend going to see your favorite concert pianist and your son’s masterful event in between dealing with insurance, just to make life a bit easier. In the meantime, here are some answers:

1. First, hire the right people to handle your insurance company relationships. For years, I was this person and I considered the maximum, quickest payment for my doctors my highest calling in the office. You need someone equally committed. How do you tell if he or she is committed? She asks a lot of questions, she researches and reads everything. This person can follow the steps that follow this one.

2. Make sure your insurance handler has all of the information, and all of the specs fulfilled, and even billing codes if you can. Just as you are a thorough surgeon, make sure your staff is as well. To show insurance companies that your office is a delight to work with (and some are not, so you will be appreciated), send along additional information on the patient. Go the extra mile to show how necessary this care is for the patient. My experience has been that the more information they had, the more they saw the procedure as necessary.

3. For each insurance, make sure you are following guidelines for that particular insurance—whether they are Medicare required or not. It takes time. If you call Medicare two times you will get three different answers. So, make sure you ask for confirmation and get it in writing, if necessary. Their bulletins will inform your staff of any changes.

4. When I used the correct modifiers the bills were paid more quickly. If they bundle the codes, they will only allow the fee allowance for the code they deem most important. Along with billing properly, use the correct number of modifiers—for each procedure, indicating that it is a separate and distinct service. Indicate any distinct procedural services. I am surprised how many don’t do this. Most of the time it is because the doctor or office doesn’t know all the different modifiers. Reading the EOB will help. Did they allow both codes separately?

5. I found that insurance companies tended to pay for more time than separate periods of time. When you can bill for extended periods of time rather than separate follow up appointments, do it. Because they are more likely to cover extended periods, use modifiers if necessary.

6. Write everything down. It would be helpful for the billing staff to have particular codes. The office should have tracking systems that record what the insurance companies pay, but it’s tough to record everything via computer. Live notes are helpful as a supplement when notes are requested. My old notebooks were three inches thick. I kept everything, allowing us to bill correctly for each service.

7. If they reject payment, resubmit the claim with additional, pertinent information on the procedure performed, so they can be better informed. They are more likely to pay.

8. Keep up with Medicare and what they send. Again, I read everything.

9. When there are any problems, confusing communication, or just downright unfair activity, get on the phone with them directly. Talking human-to-human helps tremendously. Keeping your tone and word choices professional and even cordial helps pay those bills. The more dire, the “nicer” you become.

10. Congratulate your staff for good work. Your praise means a lot, including increased productivity of all of the above.

Joan Zallee went through nursing school in Northern California many, many years ago and recently retired from managing two surgeon’s businesses.

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