While most practices understand, the first step towards obtaining optimum reimbursement from an insurance company is to operationalize a consistent and timely verification process. Even with a process in place to verify benefits, however, it is not uncommon for insurance companies to make specific representations regarding a member’s insurance coverage, that are not honored after a claim is submitted for reimbursement, often resulting in an under-payment or no payment at all to the provider.
Instituting a more comprehensive process to memorialize all representations made by the insurance company is critical to successfully challenge any discrepancies or conflicting information conveyed by the insurance company during the verification process that was not upheld, after the rendering of services.
HOW TO BUILD A MORE COMPREHENSIVE VERIFICATION PROCESS
Recording phone calls and chronicling all conversations with insurance representatives are two vital processes that should be incorporated into providers’ practices to optimize reimbursements and to combat familiar tactics such as:
- The insurance company states that ‘no authorization is required’ yet the claim is denied for lack of authorization, or
- Authorization is obtained, only the claim is denied for authorization not being requested, or
- Fee schedules are represented by the insurance company but are not honored.
Recording Phone Calls Is The Best Evidence
Recording phone calls has become a widely accepted practice not only by the healthcare industry but by service industries around the globe. Provider practices should consider following suit as a recorded call with an insurance representative is the best evidence to resolve payment disputes.
A telephone recording, for example, is a powerful tool for disputing insurance payments, especially for the out-of-network practitioner. Insurance companies have a track record of representing one fee schedule at the time benefits are verified, such as usual and customary, and reimbursing at another i.e., Medicare rates.
To illustrate the effectiveness of recording phone calls, we recently avoided litigating a case for a client by using a telephone recording, a practice that he routinely uses. In this case, the insurance representative stated that the claim would be paid at usual and customary rates. The recorded evidence was indisputable resulting in the provider receiving 100% of billed charges.
Depending on the state that the provider practices, recording phone calls may or may not require consent by the party on the other line. A one-party state requires one-party consent, which means staff can record a phone call or conversation without consent of the other party. Most states, however, are ‘all-party’ consent, which means all parties must consent that the call is being recorded. Notwithstanding, the requirement to disclose should not be a barrier to implementation. It merely means that a provider’s staff will need to be trained to state that the call is being recorded at the onset. Recording phone calls is a simple procedure to implement and has proven to be a successful strategy to obtain higher reimbursements.
Documenting All Conversations With Insurance Representatives Is the Next Best Evidence
Documenting conversations with insurance representatives is the next best practice in disputing payment of a claim. Like recording phone calls, it can be an effective tool in disputing claim disputes. Moreover, documentation taken during the normal course of business generally can be admitted as evidence if litigation is pursued.
To illustrate the effectiveness of documenting conversations with insurance representatives, we recently litigated a case, in which my client, notated the fee schedule as “RC” (reasonable and customary) during the verification of benefits process. In typical form, the insurance company paid at a Medicare rate. This case hinged solely on this notation. We argued that the provider relied on this fee schedule when performing the complex surgery. It should be noted that the doctor signed the verification of benefits document, which further strengthened the argument of reliance. We ultimately settled this case for $50,000.
When handling complex cases, practices should plan and focus on capturing vital information during the verification of benefits process in preparation for any adverse claim determination. Recording phone calls and consistently documenting all conversations with insurance representatives can yield favorable results when challenging insurance companies for payment.