I argue with medical insurance companies all the time.
Let me, however, be very specific about when and why I argue with them.
I argue with them when I think they are wrong or when I think they have made a mistake.
A real example will illustrate why and when to argue with an insurance company.
MHM has a client who performs a specific test at a consultation with a patient. He has done so on more than one occasion obviously and with patients holding cover provided by all the major insurance companies, I’ve invoiced for him many, many times.
Per normal MHM won’t reveal who the client is, his specialism or indeed the true value of his charges.
For the purposes of this example please assume the charge is £125 for the consultation and £75 for the test.
The invoice was raised and sent electronically to the insurance company.
It detailed all the correct details i.e. patient’s name, complete address, date of birth, policy number, pre-authorization number. The correct CCSD code for both the consultation and the test was used. It also indicated the correct price for each and a total value for the combination involved. In other words xxxx (the consultation) = £125. The yyyy (test) = £75.
Total value = £200.
Surprisingly, when the remittance arrived electronically from the insurance, only the consultation had been paid.
A note appeared on the remittance advice stating it was not possible to charge for a consultation and that particular test at the same time.
Except, you can.
Before picking the phone up to call the insurance company concerned I first visited the insurance company’s website.
The codes were correct.
The fees for each code were correct.
There was no indication that the combination could not be charged alongside each other whatsoever. I was pretty certain even before I’d checked that I was right but it doesn’t hurt to check. I could have been wrong.
More likely it could have been that the rules had been changed.
Establishing the facts is vital when raising invoices for medical billing.
Actually its true of all commercial situations but is dependant on what is deemed to be a fact. What some claim to be facts turn out to be anything but sometimes.
In this case, though the facts were as I thought them to be. It was perfectly acceptable to charge the two codes together.
Only then did I call the insurance company.
Having passed the normal Data Protection requirements i..e patient identifiers, etc, I asked WHY this particular charge had been reduced?
It was explained to me that the combination was invalid. It was unbundled as they say.
Except I insist it was valid, was not unbundled and further, the insurance companies OWN website said the combination was permissible.
The phone went quiet for a while and then I was told the insurance company was wrong and I was right.
The £75 would immediately be paid to the consultant involved.
Despite what you may think it is not unusual for an insurance company to make a mistake, admit they have made a mistake and then rectify it straight away.
Don’t, however, call an insurance company and twist the facts.
By that I mean don’t call them and say their fee isn’t right and should be much higher.
That is not a fact, it is an opinion.
When faced with a combination of codes that can’t be charged together do NOT separate them into two invoices one being sent on a Monday and one on a Tuesday. Don’t unbundle in other words.
Insurance companies may make mistakes but they aren’t stupid.
It is very much a case of “picking your arguments” and challenging an insurance company in the right way and on the right subject.
But it is also very, very much a case of noticing that the insurance company has made a mistake and asking them to rectify it.
The number one statement made to me by private consultant surgeons is that fees are too low (I agree for what its worth) and that insurance companies are really, really difficult to deal with.
They are not.
As regards fees, however, if you want to increase your fees the first port of call is actually to check you have a) charged the right amount, to begin with, and then b) making sure you ARE ACTUALLY PAID the right amount.
In the example above the £75 wasn’t lost, it was paid to the medical professional concerned.
Look at it this way. His total charge was £175. If I hadn’t noticed the £75 had been deducted in error, he would have received 43% less than he was perfectly entitled to be paid!