Why are reimbursements declining and patient premiums increasing?

United Healthcare CEO made the Forbes Highest Paid CEO’s list in 2012.  Making over $48,000,000 in just one single year.  Go to Forbes list.

insurance and how to beat

Top 10 Highest Paid CEO’s

I’m not against people making money in this country.  Many make millions every year and it’s ok with me. It’s HOW insurance company CEO’s make their money that is appalling.  The other 9 CEO’s on the list make their money by getting consumers to willfully buy their products/services.  How do insurance CEO’s make their money? …

How Insurance CEO’s Make Their Millions

There are 3 main ways insurances make their “gravity-defying” pay (as Forbes put it).

1. They raise premiums on consumers/patients while the economy is in a slump.  They don’t care that people are struggling to pay for food, gas, and bills.  It’s all about profits to them.

2. They let people die.  Insurances have methods in place that regularly cut-off benefits to those who use ‘too much’ of their benefits (typically those very sick).  They know this tactic is illegal.  They know they could get sued.  The know they probably won’t.  The know if they did, they can settle out of court.  They know most won’t sue.  They know they make more money and profits by practicing in these illegal ways.  They pay politicians to help them get away with these tactics.  If you haven’t seen the documentary “Sicko” by Michael Moore, watch it.  I’m not that much a fan of Michael Moore but the film was very accurate.  Much of his information came from data collected by the Institute of Medicine (IOM).  The IOM is a group of scientists created by congress to study healthcare and report on the state of healthcare in this country, for improvement purposes.  There report titled “Leadership by Example” has facts that most US citizens do not know about.  I read it.  Few have.

3. They take advantage of providers.  While healthcare is in a state of crisis they take advantage of providers by playing against their weaknesses.  This is where you come in.  You have to learn more about insurances and how to beat them.

a. They study and research their opponents.
Who are the ‘opponents’ to insurance companies?  YOU, the healthcare provider.  Just like the New York Giants studied the tapes and plays of the New England Patriots (in order to beat them), so do insurance companies study you.  The only difference is they make a heck of a lot more money than the NFL.  So how do they study us?  Through research.  So why do they study us?  What are they looking for?

b. They look for our weaknesses.
Why do boxers study the video tapes of their opponent’s fights?  To identify their weaknesses.  If you don’t know your opponents weaknesses, it’s hard pressed you’ll win.  Our weakness is that we are generous and giving.  They know we will treat patient’s for free.  They know we will go above and beyond to help OUR patients even though we know we won’t get paid for it.  Lastly, they know we suck in business.  They know all we want to do is treat, not be business people. So how do they use our weaknesses against us?

c. They exploit our weaknesses.
One way is to simply NOT respond.  They know if they simply don’t pay, it will take us a long time to figure it out and even longer to do anything about it.  Many practices pay staff to sit on the phone, being transferred from one department to another before getting a chance to tell their story.  Another way is to request more information.  They know if they request more information from us, it will take us time to put it together and this means they get to hold onto their money even longer, if not forever.  Another way is to deny payment even though there are no grounds for it.  It doesn’t matter what reason they give you.  Such as…

“Not medically necessary”
You must ask them if they had a licensed therapist review the claim. Probably not.  But if so, ask for their name and number so you can discuss their decision at the clinical level.

“Untimely filing’
Next time ask them if they were prejudiced by the untimely filing and if not, they must pay.

‘Not authorized’.
Most of the time it doesn’t matter is if you received authorization or not. They will use this excuse anyways.  Does it matter if it was authorized or not.  Doesn’t your documentation, physician referral and patient’s improvement matter?  Yes it does.

When talking with people who have worked for insurance companies I”ve been privy to information that most don’t know.  On their first day of work, on the whiteboard was written, “101 Ways NOT to Pay a Claim”.  Their training consisted of learning how to say, “We never received it.”  “It’s being processed.” And even trained to throw away claims.  This is what you are dealing with if you don’t know how to hold them accountable.

There are things you can do.  You can appeal denials.  You can apply your rights.  You can hold them accountable.  You can beat them.  But you have to TRY.

“All insurances need is for you (healthcare providers) to do nothing.” -JamesPT


1. Voice your complaint.
Don’t just silently complain to yourself.  Do something more.  Go to the Provider Coalition facebook page and post your complaints.  Help the site grow to the level where insurances can’t ignore it.  You’ll also get free advice on how to respond to insurance company tactics.  Get your associates aware of this site.  Share it.

2. Stop giving away your services and valuable time away for free.
When we go above and beyond for our patients and do things we don’t get paid/reimbursed for, the insurance company wins.  Patients don’t know any better and think their benefits are covering for good service.  The insurance companies hope and bet we’ll do this.  They actually know we will.

3. Educate patients on what’s going on–insurances aren’t paying.
Go to the Provider Coalition facebook page and download a sample letter you can give to your patients.  It helps to make them aware of the declining reimbursements and why you can’t deliver the kind of care you wish you could.  The flyer encourages them to complain to their insurances and more importantly their local congress person.  Getting patients/consumers involved is the only way to create change.  That’s the way it’s always been and that’s the way it always will be.  The only thing insurances need to keep winning and hoarding profits is for us to do nothing.  We must change.


1. Don’t let them get away with stalling and denying.  There are letters that they can’t ignore.  They’re effective in getting insurances to take notice and respond.
2. Don’t give in to their tactics.  There’s power in the pen.  Get in the habit of writing/mailing/faxing letters to insurances.
3. Don’t sit waiting on the phone.  That’s what they hope you’ll do.  Verbal discussions don’t exist and have no legal leverage.  You have to send written correspondences.

Listen to this Teleconference recording on How to Appeal Denials, Get Paid Quickly and Set Yourself Apart From Other Providers.

To learn all the details and get full training on how to appeal denials, hold insurances accountable and get on the “short list” so they never play games with you again, attend the next IndeFree Advanced Billing, Coding, and Collections Course near you.

>>>If you need help dealing with an insurance company issue, post it on the Provider Coalition facebook page.

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James Ko

I believe... "It's not the strongest practices that survive and grow, nor the most intelligent, but the ones most adaptable to change." I'm a physical therapist, private practice owner, and founder of IndeFree Association. I like reading James Patterson, Nicholas Sparks, enjoy golfing and playing guitar. I love playing with Mac and Cozy! For over 15 years, I've helped thousands of practices grow and succeed. This is my dedication.

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