How to Get Paid with Insurance


You treat Mrs. Jones today, complete your fee slip, and your insurance staff has every document necessary to bill the claim. They have the application for benefits and/or proper claim forms from the patient, along with the correct policy numbers. The staff also has all of the completed notes/letters of necessity/results required ready as attachments to send with the claims, and you send the claim to the carrier within 48 hours of service. The insurance carrier either pays your bill in full or lets you know why they are not paying within a 30-45 day window, and you have no receivables beyond 45 days. Your accounts receivable for insurance are $0.

Have you accused me of being delusional yet?


Here’s the typical office:

You see the patient, fill out a fee slip and you give it to your front desk. They, in turn, give it to the billing staff that enters the codes into the computer. In many cases, the staff chooses the diagnosis from a list you have given them without their having a shred of education on how to accurately cross link codes. The Health Care Financing Administration (HCFA) form, or some similar form, is created and then sent to the insurance company, usually with no attachments, and you are hoping for prompt payment.

Every 30 days or so, your billing staff prints out a computer log of accounts receivable and starts to call on the delinquent ones. Historically, the staff chooses to wait 45-60 days until they start to call to collect on the claims. During this time, they let the insurance correspondences back up, even though most issues have a 30-60 day time frame in which to respond before your rights to get paid expire. Most offices do not respond in a timely fashion and that is exactly what the carriers count on.

 Here are the issues:

1. You have a billing staff and most have no experience or education in collections. Usually they have no training in billing and neither do you. Collectors have to know the laws of the state that the insurance companies have to abide by.

 2. Computer receivable logs do not work. Most of the staff gets through A-M in the alphabet each month, if they are lucky. The N-Z list rarely gets the attention that A-M does. Ask your staff.

3. Picking up the phone as your primary collection tool is a failed technology. If you have 20 claims generated per day, a good collector can only get 4-5 claims resolved in a day. If you take into account being put on hold, not being able to locate the file and the callbacks required, 4-5 on the average is good. That means, if you get paid on 50% of your claims without calling and you have not gotten paid on 10 claims per day, each day in practice, you fall behind 5 claims. It’s not your staff’s fault; it’s your system that doesn’t work. It will soon be your staff that doesn’t work also, because they will quit out of frustration of working in a system that is set up for failure. Verify the facts, not with your staff, but by looking for yourself…. It’s your money.

4. When you pick up the phone, you are begging and pleading with the insurance companies to get paid, and you will fail more than you will succeed. The moment you pick up the phone, you are playing the insurer’s game and they know it. This is where the laws of your state need to be utilized as leverage to get paid for services rendered.

5. You will end up treating a good portion of your patients for free. Those letters that the insurance company sends you are designed to “paper you to death.” They know that you cannot handle the paper burden, and they have also profiled who does not respond to them in a timely manner. Read the back of the explanation of benefits. Most states require the carriers to print the statutes on the claim directly. Some states simply require that you know.

I was in a similar situation, and I was tired of treating patients for free. Well, not really for free. I had to pay for my staff, the supplies, the electricity, the insurance, the rent, the ink to write the notes, and I was liable for every patient I touched, so it wasn’t for free. I had to pay a lot of money to treat those patients.

First, you and your staff need to know the laws in your state. Start by calling your state’s Department of Insurance and asking them the mandated time frames for insurance companies to either pay or report to you that there is a legal delay in the claim. In New York, for instance, the carriers have 30 days to pay your personal injury claims (NYCRR 65.15(e)(2)) and, if they do not pay or notify you of a “legal” delay, they have to pay you 2% per month without the assignee (doctor) demanding interest payment (65.15 (e)(2)(h)). Most other states have similar laws.

If a carrier did not pay me within the mandated time frame, my office sent them a notice that, if they did not pay our claim, we would report them to the New York State Insurance Department and Consumer Service Bureau, and they would be fined $500 per day, per HCFA, as penalty by the State of New York under the “Prompt Pay Law” (Section 3224a of the New York State Insurance Law). We had a form letter that stated the law and it was sent to the carrier via mail with a copy of the HCFA form.

Again, most states have similar laws.

If there were 50 unpaid and unanswered claims each day, how long did it take a staff member to pull the claim, copy it, attach a delinquent letter and put it in an envelope? Each staff member could complete over 50 collection actions per day and we never fell behind, no matter the volume. This is versus the 4-5 you can get on the phone to complete a collection action. Occasionally, we did pick up the phone on larger claims, but our story was the same when we eventually got the carrier on the phone.

Your current conversation is, “I sent you the claim. Pay my bill…pleeeeeeeeeeease!!!!! Look at your statistics and see how well you are doing with that plan.

By using the laws of my state, we went from 50% collections to 90% of the fee schedules. The balance we either litigated and/or arbitrated and I have successfully gone through this process in multiple states.

You cannot beg and plead for your money. There are laws in every state to protect you and, those that understand the laws and use them get paid. The insurance companies profile you and know who begs and pleads versus those who utilize the law to rightfully get paid. The latter group gets paid with much greater ease.

You are entitled to get paid a fair fee for every service that you render.

Dr.-Mark-StudinDr. Mark Studin is the President of C.M.C.S. Management which offers the Lawyers Marketing Program,Family/MD Marketing Program and Compliance Auditing services. He can be contacted at or call 1-631-786-4253.

Leave a Reply