Chapter 3
Their Tactics and Their Rules

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Recap

1. The patient is the insurance company’s customer, not yours.
2. The system is rigged in the insurance company’s favor by design. They make the rules.
3. They are legally protected by the federal government.
4. They make money on interest.

So how do insurance companies pay claims, make a lot of money (from interest), and still look good in the eyes of their customers? 

5 Generic Tactics They Use

1. Make it difficult for you to get the claim to them in real time.
2. Make it difficult to prove necessity and deny claims, especially in real time.
3. Pay very slowly.
4. Pay less than they should.
5. Take the money back much later after their customer is satisfied and out of the picture.

Making Patients Hate You Instead of Them

Think about this from the patient’s perspective. They have no idea about the things we’ve already discussed. They just want to get their visits paid for because they paid their insurance premiums.

Of the five items above, which one makes insurance companies look bad in the patient’s eyes? None of them!

1. It is the doctor who has to make the claim properly.
2. It is the doctor who must show why this care was necessary.
3. It is the doctor’s fault it is taking so long for the insurance company to pay for your visit (see tactics 1 and 2).
4. It is the doctor who charged you more than is reasonable for your area.
5. It is the doctor who billed you fraudulently. Now we have to investigate.

They make the rules, right? What are the rules that help them save face with the patient while they hold on to your money?

The Rules

1. Insurance companies have 30 days to process a claim instead of paying in real time.
2. Each patient’s coverage is different.
3. They have a very complex coding system that determines what they pay you. The codes are actually not really necessary to pay. The complexity is really there to make it very difficult for you to submit the correct claim in real time, slowing down or preventing payment and increasing the interest they collect.

With only the list below and its possible combinations, the chance of making a mistake is in the hundreds of thousands.

1. 1. Diagnosis codes, ICD-10 (ICD-11 is coming, believe it or not)
   2. Diagnosis code ordering
   3. CPT codes
   4. Modifies
   5. Diagnosis code linking
   6. Number of units
   7. Timed codes
   8. One-on-one Vs group
   9. Levels of codes. Exams and re-exams, for example

4. 4. HCFA – The complexity increases more with the submission form/bill/HCFA. It needs to be sent with a lot of information. Anything that is incorrect is grounds for denial and/or delay.
   5. Remittance Advice – The EOB
      1. Taking an EOB (Explanation of Benefits) and posting the line items takes a highly skilled employee, but they leveraged technology to send the EOB to you. We’ll cover more on the economies of scale, the workforce, and technology a little later.
      2. Every payer has his or her own denial codes and format, which significantly slows down your posting.
      3. Underpayments – Finding an underpayment means your staff needs to remember every CPT allowable or contracted amount for every payer. When something is underpaid, it is almost impossible to find. It looks like it was paid after all. Over the course of your career, this could cost you tens of thousands of dollars. Very sneaky, if you ask me.
   6. Documentation
      1. Ambiguous requirements – Subjective, objective, ADL, assessment, plan. Functional improvements, outcome assessment tools. Blah, blah, blah. Thirty compliance “experts,” 30 different opinions.
      2. Matching documentation to the coding adds yet another level of complexity. Most technology does not help you get this right—your documentation matching your codes for each visit. Lots of systems say they have fast notes, but what about the coding complexity? Does it warn you when you’ve made a mistake? Are they really looking at insurance companies’ trends and improving this over time? Are they reviewing real-life claims data and updating the system to make sure your claims are accurate? More on this later when we get into beating them at their own game!

It is all nonsense really. They know it. Now you know it.

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