Claims-checking showdown: Fighting back

Insurers have special software to determine how you should be paid. Should you have it too?

By Leigh Page, AMNews staff. May 14, 2001.

Health plans use powerful computer systems to bundle, downcode and reject physician claims -- often without much explanation to those physicians affected. In part, that's because plans consider their rules and systems proprietary knowledge, not to be revealed to anyone.

But practices can fight back with an increasing array of sophisticated computer systems that try to mimic these systems and beat them at their own game.

Makers of the physician products say they ensure claims are error-free and coded properly and that the plans are paying the contracted amount. And they say they are persuading health plans to share the secrets of their claims systems so physicians have the most up-to-date and accurate information in their own systems.

These systems can be expensive -- costing a small practice tens of thousands of dollars, plus thousands more in monthly rental fees. But makers claim that savings generated offset the cost within a year, and billing experts seem to agree.

"I encourage physician groups not to get hung up on the money side, because these systems are going to more than pay for themselves," said Ken Beasley, president and CEO of Healthcare Network, a Memphis billing management company for practices. He uses a system made by VantageMed Corp. of Rancho Cordova, Calif.

The products, however, vary widely in price and quality, and some companies are just getting off the ground. While many large practices already have signed up, makers concede that few small- and medium-sized ones have jumped in yet. [...]