From a colleague in Georgia a warning of new fun and games. This is what makes primary care so much fun. We have to take time to carefully scan every payment that comes in to find these little games, then get on the phone to these guys.
We don't get the 'member' line where they are nice to people - that's where they MAKE money, so they treat 'em nice.
We have to call the 'provider' line - that's what the insurers call 'medical loss.' [Yeah, that's right folks, what we do for people the insurers call a 'loss.']
Once we key in our 'provider number' and verify it with a bunch of other codes and wait on hold and are finally blessed with the opportunity to talk to a billing clerk we can ask why they've played games with a $13.11 payment.
Why does the doc care about $13.11? Because the cumulative effect of these games will cause her practice to fail if she doesn't.
If you bill to Humana for any of their Medicare alternative plans, watch your EOB’s closely. We got 4 EOB’s in mail today and the allowable rates shown on the claims was only 88% of the Medicare allowable for the code billed. I was shorted $13.11 on each EOB and when we called them on it we were told that the problem had to do with the reduction that was put on hold a few days ago. When I pointed out that the claim was for services rendered the last week of December and that had the reduction gone into place it was for DOS [Date of Service] after 3/1/2010 and that the 4 claims in question were still prior to any change in the allowable fees. I told them that we would expect payment within 15 calendar days or we would file a complaint with the GA insurance commissioner’s office. I followed up the phone call with an official appeal letter sent certified so we can prove we tried to resolve this issue should it become necessary to take the issue to the insurance commissioner. I am tired of these plans playing games with my reimbursement. I just thought I would give everybody a heads up to watch out for shorted payments.
This is why more and more docs are ditching these games and figuring out other ways to serve their patients instead of spending their time playing The Payment Game with insurers.