Each of us has received rejections from the insurance companies. We provide necessary services and a bureaucrat decides the patient did not need them. In response to the claim submitted, the insurance company sends a rejection. The copy of the rejection that goes to the patient implies that the care was excessive, unwarranted, or fraudulent.
Some doctors just accept this, others file an appeal. But even when the appeal was filed, most offices give up and do not go beyond that one appeal. This has a cascading negative effect, and may result in putting you out of business.
What are these detrimental effects? There are several and the only way to stop them is to intensely fight the insurance rejections.
At the top of the list of negative effects is the loss of your patient and damage to your reputation. The rejection is an assault on your credibility and can destroy your relationship with your patient. The patient gets a copy of the rejection that says you are not qualified to perform the service rendered or that the care you provided was not "medically necessary". Many patients simply stop coming as soon as they get this message.
The greater devastation comes when your patient spreads the message to everyone that they know, causing other patients to drop out of care and preventing new patients from coming in. When you send a bill for your services, the patient refuses to pay for the same reasons that the insurance company enumerated. The rejection has now developed into a collection problem.
As the insurance company sees that you do not challenge their rejections, the company repeats this tactic with other patients covered by their policies. They may share the information with other insurance carriers, so that many insurance companies jump on the bandwagon.
Seeing you as a pushover, the insurance carrier may assume that you have documentation problems, and then they target you for a post payment audit. If the audit uncovers any discrepancy between your billing and documentation, the insurance company demands a refund of monies they paid you and files charges of fraud. Once the newspapers discover you have been charged with fraud, your reputation is trash and your practice becomes just a memory.
It is up to you to take the steps NOW to prevent and stop these problems from happening! Avoiding the rejections and their subsequent effects is easy. One thing sums it up: computerized electronic digital DOCUMENTATION that generates your billing.
The first step is to keep thorough, detailed and comprehensive documentation of everything about your interaction with your patient. This means a record of everything the patient tells you and your staff, all your findings, recommendations, treatment and everything said over the phone to anyone about your patient. With all-inclusive documentation, you have the tool that proves that the care and services you gave the patient was warranted and necessary. Handwritten notes, with this depth of detail, require at least 15 minutes per note per patient. Computerized electronic digital documentation that is part of an Electronic Health Record (EHR) system accomplishes the same quality of SOAP note documentation in seconds, not minutes.
The second step is to vigorously challenge the insurance company for every rejection. When you have the knowledge that your meticulous documentation supports your treatment, there is no reason to cave in and accept the rejection as the final word. For some insurance programs, such as Medicare, there is a specific multi-tier appeal process. Sometimes the first 2 appeals are just rubber stamps of the initial rejection. It is not until the third appeal that someone actually pays attention to your documentation. As long as your documentation clearly and completely substantiates your claim, eventually you will win the appeal. You just need to be persistent.
With really good documentation and dedicated persistence you will win your appeals. The more appeals you win, the less likely the insurance companies will send you rejections in the future. If you are really intense in your fight of rejections, the insurance carriers will eventually leave you alone.
Make sure your documentation is complete, have the confidence to challenge the insurance companies, take them to court, and win for your practice, your family, and your pocket.
Paul B. Bindell, D.C.
Dr. Paul Bindell is a 1975 graduate of Palmer College of Chiropractic, in practice in Rockaway, NJ since 1976. Dr. Bindell is a past Chairman of Public Relations for the Northern (NJ) Counties Chiropractic Society. In 1991, Dr. Bindell and his family began Life Systems Software so that the profession would have reliable computer programs based on real Chiropractic practice. Dr. Bindell is available to speak to your group or organization and can be reached by email at
, or you can call 1- 800-543-3001.