Stake your claim: How to fight for fair reimbursement

The AMA's new claims management resource kit can help physicians know what they should be paid and have the evidence to call insurers on any discrepancy.

Editorial. June 21, 2004.

Managed care companies don't exactly go out of their way to make the claims submission process as easy and transparent as possible.

There have been many cases of outright downcoding and intentional underpayments by plans, but often the problem with getting paid is that physicians are too enveloped in the fog of health plan gobbledygook and bureaucracy to fight for their fair reimbursement. The Advisory Board Co., a health, membership and research organization, estimates that 90% of claim denials are preventable and 67% of denials are recoverable. Based on those estimates, physicians collectively lose billions of dollars a year of revenue that is rightfully theirs.

The American Medical Association is offering help for physicians to cut through the health plan fog with its "Claims Management Resource Kit." It is an easy-to-use guide to preparing claims, following their progress and appealing them when necessary. The guide is offered at no charge, exclusively to AMA member physicians.

Consultants are quick to tell physicians that auditing their claims and taking other steps to fight against downcoding and bundling are essential tools for a practice. But putting together a system to check on insurers may seem like an overwhelming administrative hassle.

Using the AMA's kit gives physicians a huge assist in that process, making a daunting task easier to approach and manage.

The kit contains three booklets:

• "Prepare That Claim" is designed to help you and your practice review your claims-management process. It includes sample workflows for patient registration, clinical documentation, patient check-out, coding, billing and collection. It also includes sample forms to help physicians work efficiently and effectively in preparing, submitting and collecting claims.