As with most things that one does many times, practice – and preparation – make the task easier and leads to better outcomes. The same holds true for the much despised pre-certifications, denials and appeals when working with a patient’s insurance company. An article in the June 2006 Family Practice Management offers good guidance and resources to be more efficient and effective in this process.
It’s widely known that there are still unnecessary, ineffective and downright harmful “care” in the $1.6 trillion of healthcare spending in the US. As we’ve written before, major employers – who pay the bulk of the bill – want to see accountability. Led by the Leapfrog Group, they want to see that the money being spent is making a difference
in health and well-being. They wonder why practice patterns vary so widely across the country, and why the guidelines for the most effective care are not being followed by many physicians.
1. Ask the plans for their guidelines. The plan may have restrictions on their licensing agreement as to what they can share, but ask. The Medicare guidelines are public, and will you a pretty good idea of what to expect. The feds are maintain the National Guidelines Clearinghouse, a large searchable database that include a free update notification service.
2. By knowing the guidelines, you know what the plans are looking for. If you are documenting the need for the service, address the points. This is no different than any other “negotiation” – address what is important to the other person – how will this test/procedure benefit the patient? How will this help the patient in the care that will be given? If another test doesn’t add to your decision making or treatment decisions, or to the outcome of the patient – why do it?
3. If the patient’s health plan limits or does not cover the service, it will be denied. It doesn’t mean that it isn’t necessary, it just means that the plan won’t pay for it. Preventive services are the best example – most plans don’t pay for preventive care. When I take my daughter for her sports physical next week, we will be paying for it out of pocket.
4. Get the patient involved if the plan is truly not cooperating. Patients can call the plan, and they can go to their HR department and put pressure there. It’s been known to work at times.
5. Follow-up – If the plan doesn’t respond within a reasonable time period, follow-up. If you can get to know the plan medical director, do so. As with any business relationship, personal knowledge and trust go a long way in making things happen.