by Legal & Regulatory Affairs Staff
Article reviewed for accuracy July 2018
December 17, 2008 — Trying to resolve issues with managed care and other health insurance companies can be a frustrating and time-consuming experience. For example, the insurer may pay you a lower in-network rate instead of the higher out-of-network rate even though you are an out-of-network provider. Or you may have difficulty determining why the company is not authorizing certain services for your patients.
The pointers in this article are intended to help make the process of problem resolution less painful and more effective. The tips below apply to a wide range of general problems you may have with a health insurance company.
1. Anticipate problems and create a place to keep records.
The first step in dealing with insurance companies is to accept the fact that you are likely to experience payment or other problems. Health insurance companies process several billion claims annually in the United States and problems are inevitable.
You should keep records of all your relationships with insurers in a place where you can easily retrieve the records. Every contract you receive, addendum to any contract, fee schedule and any letter referring to contracts and other payment-related matters should all go into a central file or separate files for each insurer.
2. Clarify the company's basis for its action or position.
When you are disputing an action taken by an insurance company, you need to ascertain why the company is taking a particular position. The general trend seems to be toward greater transparency among companies about their policies and positions. Yet in some cases there is no clear reason for an action - for example, the company won't give you a particular fee schedule but doesn't offer an explanation. In that situation, don't hesitate to press the company representative for a clear reason.
3. Gather relevant information.
For example, if the company cites something in your provider contract, you should review the section of the contract that the company cites. If you do not have a copy of the contract, request one. Similarly, think about what documents support your position — for example, the APA Ethics Code, provisions of the Health Insurance Portability and Accountability Act and/or your provider contract.
4. Start cordially, then escalate.
The best approach often involves starting with a cordial phone call or email and becoming more assertive if your polite approach does produce results. Maintaining a cordial tone is particularly appropriate if you have an established relationship with a company representative.
5. Create a paper trail.
Keep notes documenting all your conversations that include the date, the name and title of the person you spoke with, the phone number you used and a summary of the conversation.
If your initial cordial attempts do not resolve your problem, build your paper trail by putting communications with the company in writing via email or registered letter. But exercise caution: If you include patient information in the email, be sure that you have completed the necessary risk analysis and risk management for email security risks as required by the Health Insurance Portability and Accountability (HIPAA) Security Rule. If you are not already complying with that rule, such an email may trigger your need to comply because it is likely to be deemed an electronic transmission of protected health information in connection with insurance claims.
6. Keep your communications concise.
Company employees typically handle large volumes of information and don't have time to wade through a long exposition of a problem or issue. Your communications should be as succinct as possible.
7. Affirm what you need for the company to do.
Remember that in addition to stating a complaint, you want to affirm clearly what action you expect the company to take — for example, answer a question, authorize care or pay a claim. This step may seem obvious, but it is sometimes overlooked.
8. Engage people and entities that may give you leverage.
Some companies are more responsive when you demonstrate that you know how to use leverage available to you. Professional associations, government agencies and others can help put pressure on insurance companies in resolving persistent problems. Consider copying your e-mail or letter to:
The national, state and local psychological associations to which you belong
Your insurance commissioner
Your state attorney general
Your state or federal legislator
9. Be ready to go higher up the chain of command.
If your initial company contact is not helpful, do not hesitate to elevate your problem to the next level. Politely ask for contact information for the person's supervisor. That individual may be more knowledgeable about company policies and have the authority that a lower level employee does not have to resolve matters.
10. Be persistent!
The saying "The squeaky wheel gets the grease" may apply to dealing with insurance companies. Some companies seem to operate under the policy that if they deny most requests the first or second time, the health professional will become frustrated and give up. This means they have to deal only with those who are persistent and know how to use their leverage. You should be one of those people.
One final point relates to the question of who should deal with time-consuming insurance company interactions. While some psychologists can handle day-to-day practice management activities on their own, others find that the administrative demands necessitate additional support.
For some practices, hiring support staff, engaging an outside billing service or submitting claims electronically can help streamline activities related to insurance claims processing.
Another Resource: The Managed Care Reimbursement Toolkit
As a member of APA Services, you will find additional information and resources to help you respond to managed care rate cuts, diversify your sources of professional income and manage practice finances in the Managed Care Reimbursement Toolkit.
If your problems persist despite the tips and resources noted in this article, you may contact Legal & Regulatory Affairs staff for APA Services at 1-800-374-2723 x5886.