We have been having problems over the past 8-10 months with a carrier, we will call Carrier X. We contracted with Carrier X approximately 3 years ago because these folks really enjoyed sending the check to the patient. To circumvent chasing the check, we contracted in addition to the fact that most of the patients covered by Carrier X were neurosurgery patients and probably didn't even remember being in the hospital.
Our problem, which is probably not unique to you all, is authorizations must be done by the hospital and if they aren't done, no one gets paid. My staff member who tracks Carrier X is a Dog With A Bone (that's my pet name for her)-and she doesn't let go easily which is good for us; bad for Carrier X and the hospital because believe it or not, we do business the old fashioned way-we like to get paid for services rendered. I called my representative at Carrier X and had something that almost resembled an exchange. It went like this,
Frustrated Administrator: So, I have two issues I need to discuss-the first is why aren't you adopting the current Medicare 2009 fee schedule since that is what is in our contract?
Carrier X: You are incorrect-the contract states we will implement the current year Medicare that Carrier X decides to implement.
Frustrated Administrator: Oh, well that is an interesting way to interpret that sentence because "current" usually means the year we are living in.
Carrier X: <silence>
Frustrated Administrator: We also have a problem with preauthorizations getting done in order to get paid for services rendered to your members. Since we cannot provide auth's we are dependent upon the hospital, and when these aren't done we have no way to get paid and have to consider writing the balances off, but if we didn't contract we could bill the patient. The hospital doesn't have a problem writing off some of these balances because obtaining the auth is just a little too much work for them, but for private practices, we believe in getting paid.
Carrier X: That isn't our problem and you should be able to appeal after the auth's are done.
Frustrated Administrator: How does this provide an incentive for a hospitalist practice to want to contract with you if we have no control over the one thing (auths) that helps ensure we will get paid? And, how does Carrier X handle patients that don't pay their premiums? Do you still provide coverage?
After I hung up I kept thinking about all of those conversations I had with people that just couldn't understand how we could survive if we didn't contract. Really. Chasing a check around the country? Trying to convince a major corporation that when you provide a service, the provider really should get paid?
I am not anti-contract, but I am all for getting paid and if this is how business is done with a carrier that you are supposed to have a relationship with to "make things easier", then what gives? I realize when it comes to contracting with hospitalist groups, we are still a specialty that some carriers have difficulty understanding what to do with us and it will require monumental exposure and education for carriers to understand what our role is in patient care. This isn't news to me or you, however I will admit I am in awe of how much there is to be done before hospitalists will be able to enter into relations with carriers where we are recognized for the crucial role we play in patient care.
Maybe I should send flowers first next time I speak with Carrier X. Thoughts?