Insurance Advocacy Tools and Resources

Private insurance carriers sometimes maintain policies similar to Medicare policies on their websites. However, unlike Medicare, private plans are not required to keep their policies available on their websites, so phone calls to provider relations and payment representatives are often required. Additionally, private insurers categorize these policies under different names such as Medical Policies, Medical Coverage Rules, etc.

Private insurers communicate many of their medical policy changes via newsletter so it is imperative that your practice keeps current on this literature. They will also refer you to a certain newsletter if you call to ask about a policy so it is also important to keep these in order and accessible.

The doctor's office must file the claim with the eligible insurance carrier at the time of the visit. The relevant information is the patient's eligibility on the date services are rendered. If the doctor's office does not file a claim within the filing timeframe, the patient is not responsible, hence, the claim will need to be written off. However, once the claim is processed and payment is released to provider, the patient is responsible for any patient responsibility (e.g., deductible, copay, out of pocket expenses). The practice should require all patients to complete a financial responsibility form.

The insurance company has 45 days to either pay or deny a claim once proof of loss has been received, unless additional information is requested.

Yes, the physician can charge for this as long as all patients are subject to the cancellation fee. Also the notice should be displayed prominently in the office where patients can see it.

Many private plans cover and reimburse for self injectables. However, some managed care organizations may require prior authorization for patients to obtain these medications.

All practices should be using aging reports to measure their collection cycles, rates, and accounts that need to be followed up or turned to collections. Aging reports are used to compare your collection rate cycle (e.g., 30, 60, 90 days) as well as, billing/coding errors and insurance reimbursement trends. The amount of monies in each of these brackets determines the urgency for each to be worked before claims are denied for untimely filing.

Based on the Health Insurance Association of America's survey in 2003, the top reason insurance companies deny a claim is because of duplication (48%). The other reasons in order of popularity are: termination of coverage (22%), non-covered benefit (20%), other (7%), and eligibility (3%). It is important to ensure you don't submit duplicate claims and confirm all of your patients' coverage BEFORE their visits.