Physicians and insurance companies have a complicated relationship. They both depend on each other but also seek to maintain their own margins. In the end, it is the patient that typically comes out as the winner regardless of this rocky relationship. That being said, physicians need to be adequately compensated for their work so they can offer even better care to their patients. Here are a few effective ways that doctors can get better payments from the insurance companies they work with.

Upgrading Insurance Contracts

Running a practice is hard enough without having the cash flow to match patient volume. Most doctors will secure insurance rates once and never look at the contract again unless they change payment processors. Using outdated rates not only reduces profit margins but also reduces a doctor’s ability to offer updated patient care. Health insurance is always changing, and it is critical that doctors make sure their insurance contracts change to align with the times. 

Push Back on Excessive Audits

Many commercial insurance companies will tell practices that they can audit payments post or pre-payment of the claims. They may also claim that their right to do so is listed in the contract when it actually isn’t. Too often, these “audits” result in lowered payments. Make sure that if this is listed as a reason for reduced payments, ask for proof of that in the contract. More often than not, it is not contractual and therefore can’t be enforced.

Verify Fee Schedules

Many insurance companies will get rather vague when it comes to fee schedule payouts, especially those that go through Medicare. If the payment is stated to be 100% payer of the fee schedule, take the time to compare CPT codes. This will allow you to see what Medicare allows and what is actually being paid out to you by the insurance company. Often, an insurance company will pay less than what is listed resulting in lost revenue. Always ensure that your insurance contracts follow the medical policies of Medicare as opposed to the insurance company’s policy.

Choose Which Insurance Programs to Participate In

Most common insurance contracts have an appendix listing the programs the insurance company offers. For example, auto insurance liability, physician disability insurance, Medicare, healthcare exchange products, and workers’ compensation, among others. Most doctors are unaware that they have the option of choosing which programs they want to participate in. In order to improve maximum payouts, consider limiting participation in programs that have fees that are set very low, such as some state-limited programs.

Pay Attention to Recoupment

Often, an insurance company will pay out on a claim or batch of claims only to later say a mistake was made. This process is called recoupment. Usually, the mistake is inappropriate coding, and the insurance company will claim a percentage of the total amount of claims reviewed. Not only is this number imprecise, but the claim itself is often inaccurate. Make sure that your insurance contracts give you the right to contest any audits. This will allow doctors the time to double-check that their initial coding is actually correct or if a mistake was made prior to being assessed a fee.

Improving Insurance Payments & Patient Care Effectively

Instead of being unhappy with low insurance payments, doctors can negotiate better rates. This will allow them to spend more time caring for patients and less time worrying about covering the rent. With the suggestions listed above, higher payouts are just a few steps away. 

©2023. Justin Nabity, @PhysicansThrive. All rights reserved.