Deciding to NOT Participate with an Insurance Company

August 19th, 2010 - Adam Alpers

The medical insurance company can be the greatest hero for the patient and be a nightmare too depending on the circumstances. So, is the case with providers? When a medical provider finds out that there is one particular insurance company that has become difficult to work with in his/her practice and is essentially taking more time to process claims and make calls to obtain authorizations over and over again, then they might decide to remove them from their list.

This move needs to be taken with a great deal of thought put into it. After all, cutting out an insurance company could potentially affect the revenue of the provider. Those patients who are subscribed to that particular company will not be able to have their claims processed by that doctor and will become essentially self pay and need to file their claims separately. In most cases, those patients will seek care elsewhere, not because of the care provided, just because of the needs of having the insurance.

However, if the provider notices that there are several financial pitfalls that he has to deal with in a particular insurance company, then he might as well cut them out. At the end of the day the provider has to look for the most feasible option for his business on a day to day basis. There might be also those periodic instances that the provider has ensured that he has done everything possible that has been mentioned in his contract and still the insurance company is holding, delaying, and not processing the claim.

He has entered the correct CPT® codes, provided the right documentation, followed the time line and in fact followed everything possible but he notices that all the claims that he makes are denied or even worse, delayed most of the time. This certainly sets a precedent and in that case he might as well leave that kind of insurance company behind rather than incur the loss of not only revenue but of time, over and over again.

The provider on their part must ensure that they have the correct and complete notes ready for each patient and their documents and records are all up to date. When this is done the provider will be able to ensure that he is able to see evidence in the patterns and trends that emerge.

A provider needs to find out what the concern is with the insurance company and if it can be rectified. After numerous attempts to work with the insurance company, and a reasonable time line, the decision needs to be made to remove the insurance company from your panel while then distancing oneself from that particular company based on the requirements of the contract.

Remember, in this day and age, it is not only the large insurance company that is making the decision to accept you, the provider on their panel, you must insure that the reimbursement and the effort to get paid for the work you have performed is justified or in reality, you are just providing free care for your patients on behalf of the insurance company.

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