Spine surgeons are continually facing dwindling reimbursement and payers are throwing more roadblocks their way. The claims process is often a trying experience, and can seem quite hopeless after hour-long phone calls and no money coming in the door.
"While there is an increase in negotiations where payers are working with us to resolve claims, trying to capture that money has truly been a challenge" says Barbara Cataletto, CEO, MBA, CPC of Business Dynamics, a spine revenue cycle management firm in Melville, N.Y.
Since 1998, Business Dynamics has navigated the complex world of payers, with Ms. Cataletto in the throes of carrier negotiations. Over the many years, she has become well-acquainted with emerging challenges in the claims process that can deter surgeons from following through on their claims.
When communicating with payer representatives, practices' staff members are sometimes talking to off-shore representatives who often give outdated and incorrect data on claims. At worst, these phone calls can take two hours on a single claim and end the call without results.
"Many collectors see these as delaying tactics. Often, you get stuck in this cycle where they promise to call you back but that doesn't happen," Ms. Cataletto says. "All of this is extremely labor intensive and cost ineffective. This cycle has been the history of reimbursement for spine."
Spine surgeons also face challenges within the post-surgical claims review process. During this process, payers demand practices to submit medical records proving a procedure was medically necessary. Although not a new concept, carriers are demanding more extensive information and records from across a patient's continuum of care.
"Some carriers request a patient's medical records of all the providers that treated them [during the episode of care]," Ms. Cataletto explains. "Some of these appeals can go on for years. This tactic has slowed down reimbursement over the last several years."
Many spine surgeons are becoming increasingly aggravated as the claims process could take up to 60 business days. Additionally, surgeons face denial if they make a slight change during a procedure that the carrier did not authorize. Although the process may seem hopeless, Ms. Cataletto has utilized various strategies that have helped move claims more quickly and effectively through the process.
Here are four strategies:
1. Connect with a representative who understands the process. Ask to be transferred to a representative in the United States who can relay all the correct information so you don't have to start from square one.
2. Speak with the carrier's management team. If a representative doesn't help move your claim further along in the process, demand to speak to the management team involved on the carrier side.
3. File a complaint. "Sometimes you need to stop calling the payer and take other action," Ms. Cataletto explains. "You need to rock the boat a little bit." When filing a complaint, make sure all your T's are crossed.
"In your complaint, don't talk about your aggravations with the overall claims process. Cite specific issues you are dealing with," she adds. "Make sure you have a clean claim and do your due diligence."
Providers can file the complaint to various parties including the insurance carrier's CEO or the state's attorney general office. The nature of the problem dictates who the payer should send the complaint to and whether they should send the complaint to multiple parties.
4. Get all parties involved on a call. When practitioners submit a claim, it goes through a lengthy and often arduous process. Staff members speak to a review company who refers them to the carrier who then refers them back to the review company. To get rid of the headache, Ms. Cataletto recommends getting both the carrier and review company on a conference call to see exactly where they are in the claims process.
Patient involvement may also be an essential way to drive a claim forward. As patients becoming more responsible for their healthcare dollars, they will want to be more involved.
"Patient involvement sometimes needs to be undertaken and it is usually very successful," Ms. Cataletto says. "Patients want to know if their doctors are being paid because they are paying for the service."
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