Departing travelers on London's Underground Railroad hear a recording each time the train stops to "mind the gap" – meaning the distance between the door and the platform.

 

It's good advice for physicians and their offices, too, although in this case, the "gap" is the difference between the services they want to provide and the amounts that insurance companies are willing to reimburse.

 

Physicians have been trying to acclimate themselves to this ever-shifting reality for a long time. It hasn't been easy, and in many ways, it's becoming more difficult. According to Billie Jean Davenport, director of practice management at the Arkansas Medical Society, changes in the industry affecting providers' bottom lines have occurred more rapidly in the last year-and-a-half than they have during the rest of her 35 years in the business combined. Coping with those changes has been a challenge, particularly for older physicians who expected to hang out their shingles and make a good living when they graduated medical school and instead are being forced to keep an eye on their practices' bottom lines.

 

"Physicians have wanted just to practice medicine and have forgotten sometimes about the business side of it," said Davenport. "So now they need to treat their practice as if it were a business and make sure that the structure of their office is run like a business."

 

In London, minding the gap isn't that difficult – just step over the space to the platform. Minding the gap between prescribed care and reimbursed care, on the other hand, is a little more challenging, but it can be negotiated more easily by following relatively simple principles.

 

According to Rose Ann Cato, director, network services at QualChoice of Arkansas, providers increase their chances of being paid appropriately and on time by excelling at some basic tasks, including keeping up with payers' policy changes, coding correctly, and ensuring they will be paid for services before they render them.

 

As any medical office manager knows, payers are constantly changing their policies, but they do a good job of informing providers about those changes through visits by customer service representatives, newsletters, and Web site updates. According to Davenport, someone in the office should be checking Web sites weekly. She said the AMS provides updates to payers' policies as well.

 

Other types of communication can actually make a practice more profitable. According to Max Heuer, spokesperson at Arkansas Blue Cross Blue Shield, the company generates reports for providers that inform them how long it took for a claim to be received and then processed. "We can give them this type of information so it will help them and us correct any inefficiencies from a business perspective," she said.

 

Proper use of the insurance industry's 30,000-plus codes plus their modifiers can be difficult, but it's critical to ensuring payment and to reducing the endless money chase that benefits neither the provider, the payer nor the patient. Payers' payment systems are designed to find inappropriate coding, and though Cato said that intentional fraud is rare, payments can be adjusted and patterns can lead payers to audit providers to prove a procedure was medically necessary. "That's not fun for anybody – certainly not cost-effective either for anybody," she said.

 

Meanwhile, providers can ensure they will be paid after a procedure by performing due diligence beforehand, including ensuring that a patient's insurance coverage is current. While this seems to be self-evident, it's a task that can be forgotten during the busy workday or skipped when office personnel assume a patient's coverage is still good – an assumption that's not always valid, particularly in a down economy. Most pertinent information, including patients' insurance coverage and whether or not they have met their deductibles, is available online. "From that provider's perspective, obtaining the current health insurance information from their patient is important and helps that claim sail through," said Cato, who added that her physician checks her coverage before each appointment.

 

For physicians, pre-authorization is vital in some cases and required in others. While it's best to research coverage on many procedures, it's not an option for some high-tech imaging, which won't be reimbursed without pre-authorization no matter how medically necessary it is deemed to be.

 

Despite the difficulties, according to Davenport, the Arkansas Medical Society is receiving relatively few complaints from providers about payers, and when there are problems, her organization can help solve them.