I’m going to do a follow-up to the piece we did just the other day about the worst insurance payers. We focused on denials in that last episode, and I did want to point out that there are other reasons that payers can be particularly bad, and there’s a whole range of them.
One of the big ones is a cycle time or days to pay. The variance here can be quite huge. Some payers pay in as little as a few days, while many pay in 30-35, 40-45 days. It’s not uncommon. Distribution tends to cluster around those days. Some are 60 to 75 days, and some are 120+.
Workers’ comp can be particularly terrible. We’ve seen some that are even as long as 9 months, which seems completely whacko, 220, 250, 270 days, and we’re talking about averages. There are some particularly bad ones.
Now, there’s not much that you can do about it since calling the adjudicator over and over and over again, week after week, is just going to piss them off and may cause more problems than benefits. Obviously, we can do some things.
No claim on file
Another vital metric not captured in looking at denials is no claim on file. When you are looking at denials data, there won’t be any response back if you’re looking at data in your system. If you don’t have an automated trigger set up to contact the payer at 30 days, 45 days, and if the resources aren’t there to make sure that that’s all happening, then they will disappear for an extended time because nothing is triggering an appeal since there was no denial, there was no information coming back from the clearinghouse for the payer.
When you check the status at 30 days, you will see some payers haven’t even received the claim yet. Now, some of that may be that it hasn’t been processed in their system. Some of that may be that they’re just claiming that they haven’t received it because they say it takes so long to sort of quote process it.
What are bad payers?
Now, others if you’ve got to send paper claims, and this is where again another category of bad payers comes into play, if you’re out of network, some payers will not allow you to submit claims electronically even though legally that should be the case. If you have to send a paper claim through, they say it takes 6 to 8 weeks for the paper claimed to be on file. You’re wasting your time y checking the status at 30 days. Then, of course, they say it takes another 6, 8, 10 weeks to adjudicate the claim once it gets on file, which again is completely nuts, but that’s the game they’re playing.
Even if you have proof that you submitted the claim, if they say there’s no claim on file, that’s their get-out-of-jail-free card. They get to be able to say, “Hey! We didn’t get it.” Not only do they never pay you, but they can skip a lot of legal requirements that they respond to whether they pay a claim or adjudicate it at a specific time. Again, they’re just looking for excuses, and this is a perfect one where they all proverbially throw enough of them in the garbage can to meet some internal thresholds and quotas so that they don’t have to pay claims. It’s an easy game for them to play, and so they pull that card quite frequently. Some of the worst payers are the ones that are highest in that, of course.
The Worst Insurance Payers
There can be other issues as well. The key thing here for all of these issues is benchmarking. You want to be able to know what is possible because, however you’re performing, however fast claims are getting paid, whether there are problems you’re running into, the frequency of denials, or all kinds of files or other things, the trick is knowing “What is achievable?”. What’s a reasonable threshold? What’s a reasonable level of performance? If you’re dealing with a particular payer that seems quite bad, is it because you’re having some bad luck? Is it because this is just an egregious payer, and there’s not a lot you can do, or is it because there is some solvable problem, and you want to make sure you address that?
Make sure you do get external data to compare your provider group or practice or laboratory or whatever it might be to others to ensure that you have the best performance, have something to strive for, and know what you should be trying to achieve.