Better understand typical insurance behavior by considering the following example (to be fair, most large payors make the majority of the payments in time).

A patient (with BCBS insurance) suffering from abdominal pain visits a gastroenterologist. The physician examines her and performs a colonoscopy using video capsule endoscopy (an imaging technique to help interpret the gastrointestinal tract). BCBS has specific coding guidelines (e.g. malignant neoplasm, benign neoplasm, Crohn's disease, hemorrhage, intestinal malabsorption etc.) to pay for video capsule endoscopy that are different from that of Medicare.

What Medicare thinks is correct, BCBS thinks not and vice-versa.

BCBS tends to request for medical records often after a month after submission of the claim and only after follow-up. There's also a tendency to hold the claim or even deny as a first step. After receiving medical records, a clinical evaluator might suggest that the physician could have performed a traditional colonoscopy and the treatment did not require a video capsule. At this point, we appeal and talk to the insurance company and explain the physician's point of view. Finally, it's up to the discretion of BCBS to make a payment. By this point (several weeks after treatment), the patient has also recovered but the physician is unsure of payment for a rendered service.

There are several variations to the above case depending on insurance, insurance plan, region and type of procedure, diagnoses and specialty. In another case in point, we notice that insurance behavior changes based on region. For example, they are more likely to say okay in small town Massachusetts to a provider who is the only cardiologist for a 100mile radius than to a provider in Long Island, New York where competition among specialists is intense.

The approach to dealing with insurance companies needs to change depending on the type of insurance. Think of a classroom in school. More often than not, the child that demands the most attention from a teacher gets it. The story is no different with smaller insurance companies that do not have elegant processing systems that big payors can afford. They deal with limited budgets. If their budgets for a given month are up then simply cannot pay. The game ends up with making faster payments to those practices that demand quickly and again and again.

NextServices clients are able to skip the nonsense with insurance companies. When NextServices takes on the billing for physicians we use our dedicated team to get payments 50% faster. Ultimately, we have been able to increase reimbursements for physicians from anywhere between 7% and 44%.