By: Cambria Krovic
Feel like you’re at a dead end? I’ve been there. After a year of being caught in the crosshairs between our Local Blue and the Home Plan, it was time to get creative.
The problem: Trying to return money on a specialty IOL.
The Home Plan paid in error. My billing specialist brought it to their attention, as we are obligated to do. The response back was that the claim was paid correctly. The Home Plan said all communication had to be through our Local Blue. We presented the Home Plan’s medical policy to them, but the payment decision was not overturned. After a year, our Local Blue was exhausted from this back-and-forth battle.
Why didn’t we give up? An internal audit would be performed for the Home Plan at some point. They would discover this error perhaps six months or two years later. We all know payors are NOTORIOUS for recoupments YEARS beyond the service date. The contract initially signed most likely gave them unlimited recoupment authority. I was not refunding money on a “temporary” basis, only for the payor to come back and request (demand) it two years later.
The plan: Scour the internet for contact information.
In this situation, I’m unsure which method received results because I utilized two approaches to reach a responsive and helpful contact person. The first method, I looked up the payor’s leaders and randomly began emailing top officials. The President’s email led to an automatic response stating he was out and that if any needs were emergent, to contact his assistant. I had a name, email, and phone number. The second method, I contacted the payor’s Fraud Department. This might have been a little extreme. But I knew that at some point, when trying to return their money, I’d get someone’s attention.
Within hours I received a response, and my problem was solved within three weeks. Keep in mind that this example worked in the payor’s favor. Fortunately, I have not yet had to go down this road for contract negotiations. However, I know that my methodology for identifying and reaching out to a plan’s contract representatives will work similarly.
I have heard stories of practices not being able to connect with anyone. If your office holds memberships with different associations (State Ophthalmology/Optometry Associations, State Medical Society, AAO, AOA, etc), I recommend contacting them first to see if they have any Third-Party connections. Here are my suggestions for contacting those who seem unreachable.
The important items you need are names, titles, and email addresses.
1) Contact the Credentialing/Contracting Department to request a copy of your contract be emailed to you or tell them you’d like to speak to someone to renegotiate your rates. Someone should get back to you, but it may take some time.
2) Review the payor’s website for senior leadership and the Board of Directors. Compile their names and titles. Knowing this information can help in step five.
3) Search for open job postings within the company. Here you will come across different titles:
- Senior Analyst, Network Management (Aetna)
- Analyst, Executive Resolution (Aetna)
- Credentialing Coordinator, Credential Network & Contract Management (Capital Blue Cross)
- Director Provider Contracting (Capital Blue Cross)
- Contract Analyst (Cigna)
- Director, Contracting (Cigna)
- Credentialing Rep (Humana)
- Provider Contractor (Humana)
- Network Contract Manager (UHC)
- Provider Account Executive, Ancillary Network Management (UPMC)
- Contract Specialist, Ancillary Network
4) Google and LinkedIn are your friends. Search various synonyms and formats. When you find someone also consider their territory.
If the territory does not apply to your office location, they may still be able to direct your needs.
- John Smith, Aetna
- Northeast Analyst, Aetna
- Aetna Analyst
5) Now that you have a name, email those persons using different formats of their first and last name @payor.com
- JohnDoe
- J.Doe
- John_Doe, John.Doe, John-Doe
- Doe_John, Doe.John, Doe-John
The contacts from steps one or two may have contact information to help narrow down the email format. Pay attention to the formats that bounce back rejected.
6) If you still haven’t had success, be creative. Contact Quality Care/Quality Assurance, Human Resources, Complaints/Grievances, or even the Fraud Department.
Another method I have seen used successfully but have not used myself is to contact your state’s Senators and Representatives. A colleague went this route when a national payor refused to increase rates to cover the costs of Retina injections. Demonstrate your appreciation by sending the Senator or Representative a handwritten thank you note.
Whatever approach you take, be polite and firm. Create a relationship they want that will benefit their Members and Dependents.