Insurance: The Nature of the Beast

If you have not noticed, our profession has a love/hate relationship with the insurance environment of today. We love insurance when we submit our patient's claims and they pay the benefits in a timely manner (within 30 days), but we hate the hassles when they don't. CAs and DCs, keep in mind that you are playing the "insurance game." That's right, I want to you to be prepared to face the nature of the beast.

My parents raised me with the philosophy that it's not about winning, but how you play the game. It is now so obvious to me that they had no idea their daughter would grow up to work as a health care consultant and management advisor in the insurance environment that we are dealing with today. Let me make myself clear: If your clinic has taken on the vast responsibility of accepting assignment of benefits and/or being a contracted provider for an HMO or PPO insurance company, you must play the game to WIN. And knowing how to play the game is crucial.

I want to commend the clinics and CAs out there for providing this courtesy to their patients. I was an executive director in a clinic for many years that extended the "courtesy" of filing and accepting assignment of benefits for about half of their active patients. I remember all of the hassles, responsibilities and costs that were necessary to extend this courtesy to our patients. I also remember how patients attempted to take advantage of this extended courtesy. CAs, you know what I am talking about, don't you? If a patient's insurance company denied benefits for any reason, it is always the clinic's fault they did not pay. When you would ask the patient (diplomatically) to get involved in calling their insurance company and following up, they would act as though you are just to lazy to do your job. Have you been there, CAs, or am I the only one that has experienced this scenario?

If your doctor or clinic has chosen to play the "insurance game," it is you and your doctor's responsibility to play to win. I hope this article will be of some assistance in helping your clinics accomplish just that. If you work in a clinic that is considering playing the game, I hope this article will give you some insight to prepare your clinic for the vast responsibilities that lie ahead of you to be able to win at the "insurance game."There are three areas to consider:

First, your entire staff, especially the insurance assistant and the doctor(s), must be consciously committed to providing the best professional services needed to be successful at playing the insurance game. Clinics that take on this responsibility in today's insurance environment need to thoroughly understand the commitments they are making their patients and to their HMO and PPO contracts. If your clinic's doctor(s) have contractual agreements to be a provider of care, the doctor, office manager, front desk and insurance assistant should know all the rules and regulations of how, where and when to file for benefits. If your clinic is not properly staffed to handle the load of 10/20-plus contracts, I beg you, do not play the game!

If you think your part-time insurance CA is/or can successfully handle 10/20-plus, individual contracted rules and regulations; if your services rendered in your clinic are 80% billed out for insurance reimbursement; and if your clinic's collections is consistently above the 95% ratio, then I am impressed. I want to work with that miracle worker, because in a practice that sees 200 patients plus per week, doctor(s), you are blessed. That is a CA worth every penny to your clinic. Don't let them go. My point is, every contract is different and your clinic will have to implement any changes that the contracts will send to your clinics periodically through-out your contracted year.

Please, CAs, gently remind your doctors to be sure they are documenting according to the rules stated in their contracts; that they re-examine patients within the time required of them by their contractual obligations for payment of benefits and comple all of the insurance's requested reports from the doctor in a timely manner. The doctor that has put their signature on the insurance contract is responsible for the administration of claims and benefits submitted by them and their staff members. Report to your doctor any concerns, requests and contractual updates.

Second, if you are going to be successful at playing the game, your insurance assistant, the front desk CA, and the clinic's office manager must be professionally and successfully trained and have the proper equipment to win at the game. Doctors and office managers, if you think you cannot successfully budget at least two or three professional, generic insurance-training seminars a year, you better think again. One thing my experience in our profession has taught me is that you can rely on change. Though I have never claimed to be an insurance specialist or possess expertise on the ever-changing insurance environment, I do attend at least several generic chiropractic insurance seminars a year. If your clinic has not attended an insurance workshop or training seminar this year, plan it soon.

Your insurance department needs great equipment, such as the ability to file claims electronically. Your clinic also needs generic (but current) insurance manuals and guides designed and written for the chiropractic profession. (If you email me, I can make recommendations to you on the manuals and guides I personally like to refer to rjocabs@earthlink.net )

Third, if your clinic does not have a written procedure and system implemented to track paid and unpaid claims, I implore you to start one today. I am sure most clinics have a system like this in place, but I have consulted and advised clinics that have never implemented an insurance tracking procedure of this nature. A simple and easy way to start is by beginning with this week's claims. This system can be used with both the yellow (back copy) of the individual patient's HCFA forms or your electronic claims - insurance receivable reports that are generated for your clinic. These reports are sent back to your clinic from the insurance company after they have successfully received your clinic's claims submissions. Start by making three folders: Over 30 Days; Over 60 Days, and Over 90 Days. As the insurance companies send you back the explanation of benefits, pull out the service dates from the tracking folder and staple it to the yellow HCFA copy; file it in the appropriate patient's file. If you are filing electronically, the CA can use a highlight marker to mark through the service dates they have received an EOB in your clinic. To use this type of tracking system, the insurance assistant must audit the system once per week and move currently billed services, once they become over 30 days old, into the over 30 day folder, and so on for each appropriate folder.

This way, anyone working in the clinic can review the pay status on a service claim date. This should help the tracking of claims that must be followed up on after the 30 or 60 day mark.
CAs, I do not envy your responsibilities in today's insurance environment, but for those of you that are doing it and those that will be having this responsibility in the future, I have the utmost respect. So CAs, if you're doing a great job for your clinics, my hat is off to you.

For those of you that know you need some training and guidance, do something about it before the "beast" eats you, your doctor(s) and your clinic alive.

One more thing before I close, CAs. Until next time: go out and make a difference.