Common health insurer and payer relations questions

Q: What do I do when a third-party payer refuses to provide a copy of its complete fee schedule to my practice?       

• Refer to the National Managed Care Contract database to learn the payer’s legal requirements and responsibilities within your state
• File a complaint

Q: What do I do when a third-party payer is inappropriately applying physician discounts to my claim payments?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal letter “PPO discount taken when a contract does not exist,” which you can customize and submit to the payer
• Learn more from the “Physician and other health care provider contracting toolkit”, developed by the AMA and the American Association of Preferred Provider Organizations (AAPPO)
• File a complaint
• For more information about the impact on your bottom line, refer to the resource “Is your practice losing revenue through inappropriate health insurer adjustments?”

 

Q: What do I do when I receive a discounted payment from a third-party payer with whom I have never contracted?

• Research payers’ obligations with the help of the resource “Holding health insurers accountable for out-of-network services” and utilize the “Sample letter for reference,” to notify the payer of the AMA’s definition of Usual, Customary, and Reasonable (UCR)
• Learn steps you can take by referring to the resource “Out-of-network payment challenges for the physician practice

 

Q: What do I do when a third-party payer continues to deny my procedure code, when reported with an E/M code appended with a modifier 25?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal letter “Lack of recognition of CPT modifier 25,” which you can customize and submit to the payer
• File a complaint  
• For more information about the impact on your bottom line, refer to the resources “The effect a payer’s claim edits can have on the repricing and payment of your claim” and “Is your practice losing revenue through inappropriate health insurer adjustments?”

 

Q: What do I do when a third-party payer reduces the payment on my claims when a CPT designated add-on code is reported?        

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal letter “Claims underpayment,” which you can customize and submit to the payer
• File a complaint
• For more information about the impact on your bottom line, refer to the resources “The effect a payer’s claim edits can have on the repricing and payment of your claim” and “Is your practice losing revenue through inappropriate health insurer adjustments?”

 

Q: When reporting a procedure appended with a bilateral modifier (50), a third-party payer pays me inconsistently—sometimes 150% of my fee schedule and sometimes 50%.  What can I do?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal “Claims underpayment,” which you can customize and submit to the payer
• File a complaint

 

Q: A third-party payer's policies are inconsistent with CPT codes, guidelines and conventions. What can I do?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal “ Insurers not accepting new CPT code sets,” which you can customize and submit to the payer
• File a complaint

 

Q: My third-party payer does not pay my claims in a timely fashion. What is the payer's prompt payment obligation?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download template appeal letters which you can customize and submit to the payer.
• File a complaint
• Refer to the National Managed Care Contract to learn the payer’s the legal requirements and responsibilities within your state

 

Q: What should I do if a third-party payer offers me expedited payment on a claim in exchange for a reduced payment amount?
A: Learn steps you can take by referring to the resource “Out-of-network payment challenges for the physician practice”

Q: After verifying the patient’s eligibility, the third-party payer denied the payment, stating that the patient wasn't eligible. What can I do if this occurs several weeks or months after the patient visit?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal “Letter confirming eligibility,” which you can customize and submit to the payer
• File a complaint

 

Q: How do I file a complaint with the AMA, State Department of Insurance and/or CMS?
A: Access the AMA complaint map to obtain quick access contact information for your state’s department of insurance and your state medical association.

Q: Why should I appeal claims that are underpaid or denied? What is lost if I just write off the underpaid/denied amounts?
A: When physician practices do not reconcile claims payments, or appeal inappropriately paid or denied claims, they may lose revenue and the opportunity to recover overhead expenses. You will improve your financial viability by reviewing every claim payment and by reconciling and appealing claims as appropriate.

When a physician practice challenges inappropriate claim payments, it demonstrates that it has made an effort to correct the payer’s inaccuracy. This has the potential to lead to a positive change in the payer’s business practices. Appealing claims that payers inappropriately deny may reduce future denials.

Access “Appeal that Claim,” a reader-friendly, interactive online resource to help you with appealing claims. This resource is easy to navigate, providing hyperlinks to places within the document itself and to additional AMA resources and tools. Physicians can simplify their claims revenue cycle by using this resource and its downloadable template appeal letters, printable checklists, and logs in which physicians can record important information about claims and payers.

Q: What do I do when a third-party payer refuses to provide a copy of its complete fee schedule to my practice?       

• Refer to the National Managed Care Contract database to learn the payer’s legal requirements and responsibilities within your state
• File a complaint

Q: What can I do about physician data generated from health insureres and other reporting bodies?

A: Public and private health insurers are increasingly using physician data to drive their decision-making processes on new payment methodologies, network design, patient education, and health services availability and delivery. In addition, they are using performance data to rate the quality and efficiency of physicians. Three resources from the AMA are designed to help physicians access these data and strategically use them to improve practice efficiency and delivery of care, as well as ensure that payers and other reporting bodies are not misusing the information.

Take Charge of Your Data is a guidebook designed to help physicians understand and verify the accuracy of complex physician data reports used to profile physicians. The guidebook was created to be used in tandem with the AMA’s Standardized Physician Data Report, which provides a uniform format for displaying physician data. Used together, these resources provide physicians with a roadmap to understanding how to use the payer-provided data to verify the accuracy of their profiles and assist them in providing exemplary care to their patients. Additionally, through the creation of the Guidelines for Reporting Physician Data, the AMA is working to improve the quality and utility of physician data reports.

Visit www.ama-assn.org/go/physiciandata to access these resources and find additional information on how to use these exciting tools.

Q: Where can I learn more about payment bundling, pay-for-performance and other payment options?

A: The AMA has two webinars where you can learn more about key concepts from two authors of the AMA’s “Evaluating and negotiating emerging payment options” how-to manual. The authors discuss how this manual helps physicians who are considering transitioning from fee-for-service payment to budget-based reimbursement. Unlike fee-for-service payment which rewards volume, the primary driver of the economic result in budget-based payment systems is the extent to which the actual cost of providing care to a patient population varies from the projected budget for those costs – physicians who come in at or under-budget prosper, while physicians who exceed the budget are penalized.

These webinars are archived online, so you can watch them at your convenience. For an overview of the manual and how it can help you evaluate, negotiate, and manage budget-based payment systems, including payment bundling, pay-for-performance, withholds and risk pools, capitation and shared savings, view this 12-minute introductory webinar. You can also view the in-depth version of this webinar, which goes into more detail on each of the manual's chapters, in addition to providing an overview of the manual and its concepts.

Q: What do I do when a third-party payer continues to deny my procedure code, when reported with an E/M code appended with a modifier 25?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal letter “Lack of recognition of CPT modifier 25,” which you can customize and submit to the payer
• File a complaint  
• For more information about the impact on your bottom line, refer to the resources “The effect a payer’s claim edits can have on the repricing and payment of your claim” and “Is your practice losing revenue through inappropriate health insurer adjustments?”

 

Q: What do I do when a third-party payer reduces the payment on my claims when a CPT designated add-on code is reported?        

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal letter “Claims underpayment,” which you can customize and submit to the payer
• File a complaint
• For more information about the impact on your bottom line, refer to the resources “The effect a payer’s claim edits can have on the repricing and payment of your claim” and “Is your practice losing revenue through inappropriate health insurer adjustments?”

 

Q: When reporting a procedure appended with a bilateral modifier (50), a third-party payer pays me inconsistently—sometimes 150% of my fee schedule and sometimes 50%.  What can I do?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal “Claims underpayment,” which you can customize and submit to the payer
• File a complaint

 

Q: A third-party payer's policies are inconsistent with CPT codes, guidelines and conventions. What can I do?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”

Q: How can I make sure my contract complies with the law?

• Refer to the documents “A guide to working with health plan representatives” and “15 questions to ask before signing a managed care contract.
• Refer to the National Managed Care Contract database to learn the payer’s legal requirements and responsibilities within your state as well as contract language you should look for.

 

Q: My third-party payer does not pay my claims in a timely fashion. What is the payer's prompt payment obligation?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download template appeal letters which you can customize and submit to the payer:
• File a complaint
• Refer to the National Managed Care Contract database to learn the payer’s the legal requirements and responsibilities within your state

Q: What should I do if a third-party payer offers me expedited payment on a claim in exchange for a reduced payment amount?
A: Learn steps you can take by referring to the resource “Out-of-network payment challenges for the physician practice”

Q: What do I do when a third-party payer tells me I am under an audit/review?           

• Refer to the documents “How to perform a physician practice internal billing audit” and ”How to prepare for a health insurer retrospective audit” 
• Refer to the National Managed Care Contract database to learn the payer’s legal requirements and responsibilities within your state

Q: How can I collect patient satisfaction data to improve and manage my reputation?

A: The AMA resource, "Managing your reputation," explains how you can use patient satisfaction data to ensure positive reviews from your patients and entities that publicly rate your practice.

Q: After verifying the patient’s eligibility, the third-party payer denied the payment, stating that the patient wasn't eligible. What can I do if this occurs several weeks or months after the patient visit?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download the template appeal “Letter confirming eligibility,” which you can customize and submit to the payer
• File a complaint

 

Q: Why should I appeal claims that are underpaid or denied? What is lost if I just write off the underpaid/denied amounts?
A: When physician practices do not reconcile claims payments, or appeal inappropriately paid or denied claims, they may lose revenue and the opportunity to recover overhead expenses. You will improve your financial viability by reviewing every claim payment and by reconciling and appealing claims as appropriate.

When a physician practice challenges inappropriate claim payments, it demonstrates that it has made an effort to correct the payer’s inaccuracy. This has the potential to lead to a positive change in the payer’s business practices. Appealing claims that payers inappropriately deny may reduce future denials.

Access “Appeal that Claim,” a reader-friendly, interactive online resource to help you with appealing claims. This resource is easy to navigate, providing hyperlinks to places within the document itself and to additional AMA resources and tools. Physicians can simplify their claims revenue cycle by using this resource and its downloadable template appeal letters, printable checklists, and logs in which physicians can record important information about claims and payers.

 

Q: What do I do when a third-party payer tells me I am under an audit/review?           

• Refer to the documents “How to perform a physician practice internal billing audit” and ”How to prepare for a health insurer retrospective audit” 
• Refer to the National Managed Care Contract database to learn the payer’s legal requirements and responsibilities within your state

 

Q: My third-party payer does not pay my claims in a timely fashion. What is the payer's prompt payment obligation?

• Review the educational resource “Appeal that Claim,” in particular Step 5: “Identify the health insurer basis for the denied, delayed or partially paid claim”
• Download template appeal letters which you can customize and submit to the payer:
• File a complaint
• Refer to the National Managed Care Contract database to learn the payer’s the legal requirements and responsibilities within your state

Q: How can I learn about some of the practice management system and clearinghouse vendors offering workers' compensation electronic billing (eBilling) solutions?

A: Access the AMA's workers' compensation vendor directory, which introduces vendors that may assist physician practices in automating workers' compensation claims.

Q: How can Iearn about workers' compensation, property and casualty electronic billing (eBilling)?

A:  Visit www.ama-assn.org/go/workerscomp to access the AMA's workers' compensation, property and casualty eBilling toolkit.  Here you can also retrieve state-specific resources, by accessing an interactive map providing information n state-specific resources on workers' compensation medical reporting and billing requirements, state rules and regulations, how to file an appeal, and more.