Strategy Review
In most cases insurance companies have 45 days to process the claim once they receive it. Key words, process, and receive. Remember, they make up to 50% of their profit from interest earned on your money. Not just premiums they have collected from patients. The insurance company strategy comes in four basic flavors.
- Delay claim submission
- Prevent claim submission
- Prolong the “processing” time.
- Take the money they paid back from the doctor.
Now we know their motivation. If you look at the chart below it is pretty obvious. What tactics to they use to make it happen?
Tactic # 3 – Coding –
Here is one place where they exercise their power by making simple things complicated. It seems pretty simple on the surface. There are a few diagnosis codes, a few procedure codes and then maybe a few modifiers. But then add diagnosis code linking. Most docs don’t even know what this means. This means if you have four diagnosis code and five procedures you can designate which diagnosis code goes with which procedure. Shoulder pain goes with the extremity adjustment. To get paid for that extremity code though, some insurance companies, not all, require a specific modifier. You only have four diagnosis to work with. What if you have five procedures and you can’t link all of the procedures to the diagnosis codes that you have? You would like to add more but you can’t. Some diagnosis code are not accepted for extremity adjustments. The result here is simple. We went from a few codes to thousands of combinations. It is ambiguous leaving the doctor confused delaying not only payment, in some cases outright claim denial, but delay in the submission to begin with. It is not by accident. After seeing hundreds of thousands of claims being processed and denied I am sure of it. Delay is how they make their money right?
