Ophthalmology practices everywhere are struggling to collect money that health plans owe them. Until insurers are forced to change, providers are almost, but not quite, on their own. Nationally recognized managed care and practice management consultant Gil Weber recommends these strategies for collecting appropriate reimbursements.

• Get it in writing.
Ask plan administrators to send you written descriptions of their requirements for various levels of service. And be certain that such requirements are tied to the provider agreement. For example, precisely what needs to be documented to justify a Level 4 Evaluation and Management (E&M) code? If the payer can�t or won�t provide written documentation, be prepared for unending downcoding disputes.
• Find out who�s reviewing your claims.
Ask if the payer is using an outside agency to review its claims and to make downcoding decisions. If the answer is yes, demand written documentation of the standards that the outside agency uses to judge the validity of your claims. And be sure you know your rights under your state law, including the number of days your state specifies that you have to submit any supplementary documentation.
• Get a definition of a "clean" claim.
It should be in your provider agreement or, at least, a document incorporated by reference. If it�s not defined now, then try to have your provider agreement amended as soon as possible.
• Bring your staff up to speed.
Make sure your billing assistants know the requirements for each plan. You may find it helpful to create a submission matrix for each plan and have your claims software automatically flag any required field not completed according to the payer�s standards.
• Use electronic billing
. This can be especially helpful when your billing system is integrated with a software program that flags questionable information or empty fields. Such an approach should speed up the process and reduce the chances for mischief by the payer.
• Document every claim that�s been denied, downcoded or delayed.
After documenting, report outrageous behavior to your elected representatives and to your state department of insurance. Keep accurate records of claims not paid within stipulated time frames.
• Pay attention to the timing of payments spelled out in your provider agreement.
You should do this even if your state has a prompt payment law. Far too many provider agreements are signed without payment timing provisions, leaving the door open for payer mischief. Payers can use all sorts of contractual tricks � words such as "Health plan will use its best efforts to pay all claims by the 10^th of the month." How can you prove that the payer is not using its best efforts?