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From: The Rheumatologist, October 2008

Five Answers You Won’t Get From Insurance Carriers

Have you ever called a carrier and asked why something was denied? If you work in a rheumatology practice, chances are you have, and you probably hung up feeling even more confused than before you made the call.

ACR Coding and Reimbursement Specialist Melesia Tillman, CPC, CCP, jokingly says, “This is the insurance company’s sneaky way to drive you all mad,” but she knows the joke often seems to be on the confused caller who is trying to provide quality care for a patient.

With nearly 20 years of previous experience working directly for insurance carriers, Tillman has come to the conclusion that, “to survive in today’s insurance game, your staff should be fully aware of what a carrier is actually requesting from you in order to get your claims processed correctly.” It is frustrating to discover that many of the quirks of the system cannot be worked around, but understanding why you are told certain things and noting what steps you can take to move things along will help you better run your practice and save you time, energy, and frustration.

Tillman gives you an insider’s perspective to five commonly asked questions about insurance carriers:

Moving to an EMR

From the new and innovative practice models to the consumerization of health care, the ACR practice advocacy department is committed to keeping abreast of threats, opportunities, and changes that will affect rheumatology practices today and in the future.

One recent change to the scope of practicing medicine is the growing demand for all medical practices, regardless of size, to go electronic.

The ACR understands that changing to an EMR system can be daunting, and new tools to help your practice cope with this movement are in the works. The ACR will soon launch its EMR User Review Web site, which will serve as a consumer review forum for ACR members who have an EMR in their practice to share their firsthand thoughts and experiences with other members who are looking to invest in a system for their practices.

In addition, the ACR is hosting an EMR vendor challenge at this year’s ACR/ARHP Annual Scientific Meeting. This challenge will feature four top EMR system demonstrations using a preset, rheumatology-specific mock patient–provider encounter. Not only will this event introduce attendees to the EMR systems, it will demonstrate a simple method to conduct in-office demonstrations that will cut through the vendor sales pitches and to the core functionality and usability of the EMR.

Finally, for those physicians who have already introduced an EMR in their practice and looking to customize their system, EMR templates soon will be available through the practice advocacy section on the ACR Web site.

Make sure you add to your list of favorites.

Q. Why is a claim denied because it is not “medically necessary”?

A. This likely means that your diagnosis code does not match that particular service. The carrier will not tell you the correct diagnosis code to use, so you must look at the medical policy—which can usually be located on the carrier’s Web site—to find that information yourself.

Q. Why do customer service representatives tell me they can only take a certain number of inquiries per phone call?

A. As frustrating as this is, it boils down to quality assurance. When a customer service representative limits your number of inquiries, it is usually because his or her quality of service is based on the wait time to answer calls—in other words, the ability to turn over a high call volume. If a representative is on a call with one person for too long, it increases the wait time for other callers; therefore, the representative’s quality would be at an unacceptable level. There is no way around this one—particularly with CMS—as this is usually policy. Your best option is to make sure you prioritize your cases and questions before you get on the call and have all information for each case in front of you. This will give you the opportunity to make sure all of your questions are addressed and will allow the representative to maintain the quality level the carrier has deemed appropriate.

Q. I have placed multiple calls to get a claim corrected. Each time, the representative tells me it will be corrected, but there has been no progress. Why are representatives telling me one thing and not following through?

A. This is about getting you off of the phone (i.e., quality level), or the representative does not understand medical claims processing. Often the customer service representatives you speak to have just enough training to answer the phone and take a message but not enough to truly understand and answer your questions. To prevent this pattern from continuing, always document the date and time of each call along with the name of the representative who helped you. Once you have documented a few calls with failed results, you can take this documentation to a supervisor of that carrier by calling the customer service number and immediately asking that the call be “escalated to the supervisor.”

Q. Why is a claim denied for “medical records” even when the patient has been getting the same treatment for years?

A. This could mean that they have hired an outside firm to help cut costs, and because that patient is on an expensive drug, they want to see if the patient still needs the treatment. Unfortunately, there is no simple way around this. You will have to provide the documentation to keep this claim moving. To save time and effort, make sure you meticulously document each case (taking advantage of your electronic medical record [EMR] if you are using one) so you can quickly resolve this by providing the information requested.

Q. When I call and tell the representative I have sent in the requested medical records several times via certified mail, which was received, he tells me they still do not have the records. What could be the cause of this?

A. The insurance company may outsource their calls. If this is happening, it is likely the customer service representative cannot verify if the records were received because he or she isn’t in the office where they were sent. Tell the representative you do not want a general mailing address for medical records but the name and address of the person who should be receiving this type of communication. That way, your mail is going to a specific person—not just to the mail room.

Contacting insurance carriers can be both time consuming and frustrating to your staff. The tips and tricks above are not always guaranteed to work. As anyone who works with insurance carriers—or calls any type of customer service line—knows, each company has a different set of policies. However, rheumatology practices should take the steps to be as well prepared as possible when making calls to carriers.

By doing some research beforehand on the carrier’s Web site, and by knowing your state insurance regulations, your staff can save themselves a lot of time and effort. If you have exhausted your options, the next best step is to contact your state insurance commissioner to file a complaint, and to contact your county and state medical associations for additional support in resolving the matter.

For more information on how to effectively communicate with insurance carriers, contact Melesia Tillman, CCP, CPC, at (404) 633-3777, ext. 820 or by e-mail at


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