PRACTICE MANAGEMENT
Claims detectives Auditors make sure physicians paid properly
BY CRYSTAL ZUZEK Many physicians suspect insur- ance companies pay them too little too late. Many feel they lack the time and resources to do much about it. Plus, let’s face it: The thought of holding big businesses accountable for coughing up the dough they owe is an intimidating endeavor, to say the least. But one physician made the decision in 2011 to do just that. Juliet Breeze, MD, former chief executive offi- cer of Richmond Bone and Joint Clinic, knew some insurance companies didn’t always pay the 19 physi- cians in the group on time. But she believed chasing down claims one-by-one would be a futile undertak- ing for her billing staff. “We had a great billing department that managed the practice’s revenue cy- cle carefully. We were very aware some payers weren’t paying us in a timely man- ner, but it seemed like a waste of time to try to en- force prompt pay compli- ance on a claim-by-claim basis. We’d end up spend- ing more money trying to recover the penalty than we were owed,” Dr. Breeze said. Dr. Breeze, who’s now chief executive officer of Next Level
ance plans. The law enti- tles physicians to penalties and interest for late pay- ments and underpayments that occurred over the past four years. (See “TMA Wins Passage of Prompt Pay Law,” page 59.) Frustrated, Dr. Breeze
resolved to take control of the practice’s payment concerns with insurers. She hired nVenio Analyt- ics of Austin to analyze the practice’s payer contracts and fee schedules to deter- mine whether they were in accordance with contract terms and to identify late payments. nVenio is one of several
Texas companies that use auditing software to pro- vide such services to medi- cal practices.
“The practice saw a
Juliet Breeze, MD, hired nVenio Analytics to review her clinic’s payer contracts and fee schedules to see if it was being paid properly.
benefit in having a third party examine our con- tracts and payments. We wanted someone to audit the whole process to de- termine how the payers we contracted with were performing,” she said. The analysis findings were eye-opening, Dr.
Urgent Care in Sugar Land, refers to Texas’ prompt pay law, which gives the Texas Department of Insurance (TDI) author- ity over payments from fully insured commercial health insur-
Breeze says. Not only did she discover the practice was paid late on many occasions, but also a fee schedule error by one carrier resulted in tens of thousands of claims either underpaid or paid in violation of the prompt pay statute over about two years. “nVenio found that if we were to be paid the actual penalties
August 2013 TEXAS MEDICINE 57
MATT RAINWATERS
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