Leading the Business of Healthcare
RCM Advisor

Quarter 1 2023 - Volume 28, ISSUE 1

Payors Are Unresponsive – What to Do?

Feature Story

By Olga Khabinskay, MBA

Having payors respond to your enrollment, credentialing, and billing questions can seem impossible. It is as though they are holding your application and claims hostage, but it doesn’t have to be this way.

You can take back control of your credentialing and billing payor challenges. Start communicating with the payor’s leadership team and learn how to go further through the process.

There are steps you can take to get attention to your delayed enrollment applications and unprocessed claims. Some steps will need involvement by the insurance leadership team, while others will require assistance from available government agencies in your state. Remember, there are always solutions to issues with payors.

Here are a few of the proven, easy-to-implement strategies that will help you get answers to long, overdue questions:

  • Keep track of all communications with payors. This timeline will provide a comprehensive summary for your next level complaint with the insurance leadership team or state agency when you are filling a complaint.
  • Research names and contact information of the leadership team who manage the regional or national contract. Look for specific titles:
    • Chief Executive Officer (CEO) 
    • Chief Medical Officer (CMO) 
    • Senior Vice President of Provider Solutions
    • Director of Network Services
  • Send an email or letter signed by the provider with all details of your case, requesting their review and response. Always provide the best way to reach you directly.
  • Make sure to copy the names of representatives who are working on your case on this letter. This will get them moving faster on your behalf. Determine when you should and shouldn’t involve an attorney in the process.
  • Pinpoint when it is really worth your time to contact payors, and when you should wait before filing a complaint.

Listed below are some suggestions on filing a complaint with the correct agency/department:

  • For Medicaid plans, you can submit a complaint to your Department of Health (DOH) local office, Healthcare Provider Rights Division, Consumer Affairs Department, or Insurance Department at DOH.
  • For Medicare Advantage plans, you can submit a complaint to your regional CMS office. To find your regional CMS office, go to this link.
  • For union plans, you can file a law suit.
  • For commercial payors, you can file a law suit, file a complaint to the Better Business Bureau, file a complaint to the DOH, and/or file a complaint to the State Insurance (Financial Services) Department.  
  • Always copy the CEO and MCO. 

If none of the options listed above result in a satisfactory outcome, there are still few more avenues to take that may resolve your case.

  1. Restart the case 
  2. Hire an attorney 
  3. Bring the case to the media to get attention

Your final action plan will be based on your practice needs and patient volume. If you decide to terminate an affiliation with the plan, make sure to take enough time to perform a correct evaluation of all the pros and cons impacting your case. 

Olga Khabinskay is the director of operations at WCH Service Bureau, Inc. and a member of HBMA’s Commercial Payor Relations Committee.