It's not a question of "if" but rather "how" insurers are hurting your cash flow with unfair tactics too well-disguised or too convoluted for you to notice and understand. But despite their sleight of hand, you have the power to hold insurers accountable for their actions by recognizing and combating these 3 common dirty tricks.

1. Manipulated contract rates and provisions. You may have come across insurers who try to dictate fee schedules and refuse to budge from "agreed upon" payment schedules. These contracts of adhesion — basically imbalanced "take-it-or-leave-it agreements" that give 1 party all the bargaining power — can be deemed invalid in a court of law. Calling out insurers who refuse to negotiate the terms of your contracts will often settle the issue before legal intervention is needed.

Perform a cost analysis to determine a bottom-line rate for cases affected by the unfair payment schedule. Account for implants and high-cost disposables; all the expenses you need to recoup to make the cases cost-effective in your center. Tell your insurer that the rates you're working with are unacceptable (you'll have a strong case if they're at or below Medicare's allowable rates).

Combat the inevitable pushback by walking up the insurer's management ladder, stopping only when you find a willing negotiator. Express your displeasure with the current payment schedule, but hold back on giving a payment rate you'd find acceptable. Let them do the talking, all the while seeing if you can work them up to the rate you previously calculated. The best negotiating tactic is to let the other party make the offers. Why suggest 140% over Medicare's rate if the insurer is willing to offer Medicare plus 170%?

2. Changing or rearranging procedure codes. When 2 or more procedures are performed during a single case, insurers typically reimburse the primary procedure at 100% of its fee schedule rate, the secondary procedure at 50% of its scheduled fee and the 3rd, 4th and 5th procedures at 25% of full reimbursement. Insurers sometimes flip-flop higher-paying primary procedures with lower-paying secondary procedures, giving you full reimbursement for a portion of what you're entitled. Recognizing this deceptive tactic requires constant checks of the explanation of benefits to ensure you're receiving proper and full reimbursement. File an appeal with the insurer if you notice anomalies between what you should be receiving and your actual payments. It's an appeal you'll likely win.

3. Financial incentives. Insurance companies have spent vast amounts of money over the years studying healthcare provider responses to various denial tactics. Employees, contracted physician-reviewers and managed care companies are rewarded with substantial financial incentives in return for innovative tricks that increase an insurer's profit margin. Trained carefully, insurance employees are also instructed on the use of specific wording and ambiguous statements such as "cost containment measures" or "utilization management" to conceal true motives for withholding benefits, while convincing providers, employer groups and policy holders their actions are justified.

One of the providers I work with recently submitted 3 identical requests to obtain prior authorization for a weight-loss surgery. Each request met the payor's requirements. A staff member later notified me that 2 of the 3 patients were denied based on failure to supply specific documentation. I knew without even reviewing the letters of denial who the physician-reviewer was that denied the authorizations, and that a separate physician-reviewer was involved with the 1 approval. It has been my experience in working with this payor that this particular physician-reviewer denies every request without proper acknowledgement or review of documentation submitted. I contacted the insurer, who confirmed they had received the required documentation. The representative refused to have the documents reviewed again by the specific physician. I then demanded that the insurer disclose the financial incentives offered to the physician-reviewer involving pre-service claim denials based on rights of disclosure. They refused. I submitted a detailed appeal to the insurer's CEO, complete with the notification that they were legally obligated to disclose the financial incentives given to their employees. The 2 weight-loss procedures were promptly approved.

Fool me once...
It takes experience, determination, dedication and some good old-fashioned chutzpah to get denied claims approved. Insurers are banking — literally — on the reality that most healthcare providers lack the expertise and time to properly research and fight back against denied claims. It's up to you to put an end to the game-playing.