The Claim Game

A number of small steps can add up to big time savings and help ease the confusion of dealing with insurance claims.

By Shelly Wilson

Shelly Wilson is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 10.8, November 2000, http://www.momentummedia.com/articles/tc/tc1008/claim.htm

As increasing numbers of teams avail themselves of the non-traditional season, more strength and conditioning programs are pursued year-round, and participation in athletics continues to grow, so grows the likelihood of injuries among the student-athletes you care for. And for every athlete directed to off-campus treatment for x-rays, surgery, or diagnosis, one inevitable obstacle looms large: the insurance claim.

Those mired in the process daily know that dealing with student-athlete insurance goes far beyond filling out forms. It requires decoding each injured athlete’s policy, locating participating providers in your area, obtaining necessary referrals, tracking payments, and liaising with parents. Multiply that by a few hundred incidents per year, and many athletic trainers find themselves struggling to fit their full-time jobs—seeing to athletes—around paperwork and phone calls.

Thankfully, there are ways to ease the burden of the claims process. In this article, we’ll suggest shortcuts, time-savers, and tricks of the trade employed by your fellow athletic trainers.

Ultimately, the process is the same for everybody. Providers are given the primary insurance information for the first round of billing. Whatever balance primary insurance doesn’t cover is then submitted to the athletic department’s secondary insurance. In some instances, athletic trainers opt to absorb the remaining costs through a budget line rather than deal with the high deductibles of the secondary insurance.

Why athletic trainers take on the task of filing and tracking claims for student-athletes, and to what extent, differs. Some view it as the best means to protect their budgets from erosion. Others do it simply because it’s in their job description. And still others do it out of a commitment to the athletes and their parents.

“These student-athletes are kids,” says Cindy Stout Kubiet, MEd, ATC, Director of Sports Medicine at the University of Maryland-Baltimore County. “They’re on their own for the first time, and they don’t know to ask if a provider participates with their insurance. Half of them don’t even know what their insurance is. It’s in our best interest, as athletic trainers, to not have angry parents saying, ‘You cost me a $400 bill.’ And from my perspective,” she adds, “having the insurance company pay the bills means I have more money in my budget.”

YOUR OFFICE
Although many of the complications that arise from claim management originate beyond your office doors, there are steps you can take in your own environment to enhance claim efficiency. The first is to consider if your current set-up for managing claims suits your time allowance and management personality.

For many athletic trainers, who handles the process is determined by which is more valuable to their program: time or money. A lucky few athletic programs hire full-time staff to oversee student-athlete insurance claims. Other programs are fortunate enough to have the financial freedom to allow ATCs to supervise the process in a limited capacity—trading higher incurred costs in exchange for the ease of sending athletes wherever they prefer. This leaves the athletic trainer with an involvement that requires little more than completing the injury form. These, of course, are the minority. The majority of athletic trainers must manage the entire process with careful attention to budgets, deductibles, and premiums.

“We have three certified athletic trainers who deal with the process,” says Jim Rudd, MEd, ATC, Head Athletic Trainer at the University of North Dakota. “One handles all the football bills, one handles all hockey claims, and another handles the variety that come out of the remaining sports. And they all follow the same system, so if one athletic trainer is unavailable, another can step in and track down information.”

Kubiet, on the other hand, feels that to appoint someone would simply consume twice the time. “I would love to have somebody who could work in this area,” she says, “and there have been plenty of times when the administration has proposed a work-study student. But I’d end up having to check everything they did. In my opinion, the athletic trainer really understands the medical industry and how this whole process works better than a clerical person in the athletic department. And if somebody [less experienced] in the department handles that process, eventually you may end up paying some bills that you shouldn’t be paying. Plus, when it comes down to the insurance company needing information on the date of injury or the providers the athlete has seen, the questions would end up coming back down to me anyway.

“I envy the places that have somebody who does this, because my managing it means time away from my patients,” she continues. “But as annoying as the process is, I have to balance my budget, and what comes in as medical bills is unpredictable. I can’t underwrite $70,000 worth of costs on surgeries or MRIs just because I don’t want to follow through with the athletes’ HMOs. I need to control those costs. Therefore, the more control I have over the claims process, the better off I am.”

One time-saving technique is to take the electronic approach. Inputting student-athlete information in a database will not only allow you easy access to insurance information at the touch of a button, but can also help you automate tedious tasks.

“We have all our athletes databased in FileMaker Pro,” says Maggie Kessler, Athletic Insurance Coordinator at Rutgers University. “That’s how we send out our parent mailings. On file, we have all the blank pre-certification forms and injury notification letters for the parents. Using the program, we can print out those documents with their names already on them.” If you’re uncertain about which software would best meet your needs, ATCs suggest contacting your school’s information technology coordinator to discuss your options.

Another technological necessity is a hands-free telephone. “You need to have a head set,” says Kubiet, “so you can walk around and evaluate athletes while you’re on hold with the insurance company. Because a lot of phone time is dead time.”

Less high-tech, though no less useful, office aids are quick-reference cheat sheets. Try to side-step making phone inquiries about which local providers participate with Brand X insurance by asking office managers within your circle of favorite providers to send you a complete semi-annual list of insurance companies they participate with. One quick look and you know if your athlete will be covered if he or she goes to a particular local provider group. Similar cheat sheets can also prove useful for quick-glance information on individual student-athletes.

“On the wall of the football stadium’s athletic training room, I keep a printout of every football player’s name, their parents’ names, their home phone number, the name of their insurance company, and whether or not their policy is with an HMO,” says Steven Cole, MEd, ATC, CSCS, Director of Sports Medicine at the College of William and Mary. “And I have a copy of that sheet in my other office as well. If an athlete gets hurt and I look up on that sheet and see it says they’re a Kaiser-Permanente patient, I’m going to send them straight to the ER because that’s the only way that anything is going to be covered.”


THE PARENT TRAP
From the beginning, parents can be a source of problems—from providing incorrect insurance information and having unrealistic expectations of the athletic program’s accountability to them and their child, to the great paper chase you must engage them in. To save yourself hold-ups later, athletic trainers agree that communication with parents has to occur before an injury ever takes place.

Each summer, athletic trainers send athletes and their parents pre-participation materials explaining the school’s billing policy and the athletic department’s secondary or excess policy coverage. A recent addition to that package, in many instances, is a legal document that parents must sign and return indicating that they understand and accept the school’s injury-management policy and procedures—that the athlete’s primary insurance will always be billed first, that the athletic department’s policy is only a secondary policy and will only cover athletic-related injuries, and that it’s the parent’s responsibility to make sure all reimbursement is forwarded to the provider.

Another key document in the pre-participation materials is the student-athlete insurance coverage information form. Since this is the information that athletic trainers work from during the claims process, it is critical that all information is complete and accurate. Generally, forms request the name of an athlete’s insurance provider, group policy number, policy type, which parent is the policy holder, who they are employed by, and whether pre-authorization is needed. But one critical piece of information that should also always be requested is photocopies of the front and back of each athlete’s insurance and prescription drug cards. This, say athletic trainers, is vital because not only will it be your quickest source for correct information if, for instance, the wrong policy number is provided on the insurance information form, but they are also the cards that tell you the after-hours authorization phone numbers and will allow you to defer some of the costs of the student-athlete’s prescription medications.

Astute ATCs have learned, though, that just because the paperwork has been completed and returned, doesn’t make it reliable. This is why it’s so important to make yourself available to families during this initial paperwork phase. “At least a third of parents will provide you with incorrect information,” says Cole, “but we try to guard against that in the informational letter we send by encouraging parents with questions or concerns to call me. In the summer, I field a lot of phone calls from parents.”

Managing the communication process with parents once an injury takes place is also an important component of the insurance claims process, because often it’s the parents who will receive the explanation of benefits information you need to submit to the secondary insurance company, and sometimes, the claims check. A delay on their end can mean a provider goes unpaid and continues to hound you for money. Although the pre-participation paperwork covers the parents’ obligation in these matters, many athletic trainers find they can expedite the claim if they re-establish contact with the family once an injury occurs.

And because student-athletes’ parents may change jobs, it’s also critical to update each athlete’s insurance information annually. “If you don’t try to keep up-to-date with coverage changes,” says Kubiet, “you end up sending the athlete for treatment based on his or her previous coverage only to discover that that coverage isn’t in effect any longer. Then you have to retrace your steps and bill to the new insurance company, which takes more time. And if that new insurance company is an HMO with a referral system that you didn’t follow, you just cost yourself a lot of money.

“That’s why if we have a big ticket item in the $600 to $800 range—an MRI, a CT, or a bone scan—as a precaution, I’ll usually call the parents to verify that their insurance is the same as stated in their file.”

PROVIDERS
Of all the parties you must coordinate with to organize care and get claims paid, the provider may seem the most hassle-free. After all, once you identify the correct one for that student-athlete’s policy, your remaining efforts are primarily to ensure that they get paid. But providers can, in fact, pose their own challenges to claims management. Unorganized billing systems, slack primary care referral coordinators, and persistent search parties for payment can all mean more work and headaches for the athletic trainer. For that reason, it’s important to attempt to foster a rapport with those you work with most regularly at your providers’ offices. Doing so may mean the difference between smooth professional service and serious stress.

“The people I have good relationships with know it’s going to take four to six weeks to process a claim,” says Kessler. “They know they’ll get paid eventually, so they don’t bug me. The people who I don’t have good relationships with, on the other hand, call me every week. But it’s hard to build a rapport with some of the providers, because they don’t trust insurance companies [and are used to struggling with them to get paid].”

“A lot of the hassle really comes back to the primary care office,” says Kubiet. “If the primary care office doesn’t have a dedicated referral coordinator—if it’s a nurse or an office manager filling the role as a part-time function–you’ll often hear that it will take five days to get a referral. Well, it doesn’t take five days to get a referral. It takes that office five days to get around to doing it. And if you’re working with an office with 12 doctors and only one referral coordinator, you’re going to wait for that referral.”

But according to Kubiet, if your athlete needs that referral for his or her primary insurance to cover the treatment, you’re not helpless. Your own preparedness can speed up the process.

“Often, I’ll do some of the work for them,” says Kubiet. “I’ll ask for their fax number and tell them that I’ll send all our dictations from our physicians as soon as I receive them. Then I’ll provide them with the ICD9 code, the diagnostic code for the injury, and who I want the athlete referred to. And as soon as they realize I’m going to share information with them, they’re more responsive.”

A lot of time and money can also be saved on claims by organizing mutually beneficial special arrangements with key local providers. When Towson University Head Athletic Trainer Terry O’Brien, ATC, MEd, realized how many x-ray claims he was submitting and tracking each year, it occurred to him there might be a more time- and cost-efficient way to acquire that service than continually chasing down insurance referrals. O’Brien ultimately helped negotiate a flat-fee contract with a local radiology group that allows him to control expenses and circumvent huge amounts of insurance hassle and paperwork.

“X-rays are fairly common in athletics, and it really was an accounting nightmare to keep track of every picture taken and to get a handle on what those services were going to cost us year to year,” says O’Brien. “In trying to put together my budget, I figured if I could save money in some areas, I could use it in others. I had heard of other trainers getting certain benefits by being affiliated with a hospital, and I wondered if a group in my area would be interested in doing this.”

A number of local radiology groups were interested, and by contracting with just one group, many of both parties’ burdens were alleviated. Through the arrangement, all basic x-ray needs are directed to the contracted radiology group and each x-ray is billed to the athlete’s primary insurance. Charges not covered by primary insurance are applied against the arranged fee. But even if x-ray services provided in a given year exceed the contract’s fee amount, Towson’s athletes are covered, including out-of-network HMO athletes. By using this system, Towson University saved approximately $8,500 in x-ray costs last year—charges that didn’t have to be applied to the secondary insurance or deductible.

Athletic trainers at Illinois-Wesleyan University also recently discovered a way to streamline interaction with providers. By utilizing a specially designed software package, select providers can access the athletic trainer’s insurance information database and retrieve the needed information on each athlete’s primary insurance.

“Most of our services are provided through the Sports Enhancement Center, a local orthopedic assessment group,” says Bill Kauth, MS, ATC/L, CSCS, Head Athletic Trainer at Illinois-Wesleyan University. “We keep all our student-athlete insurance information on a computer, and about two years ago I asked our university’s information technology coordinator what he recommended for transferring information from a base computer to another computer. He suggested a program called PC Anywhere. So the Sports Enhancement Center and our department both bought the same software. Now they can log onto our computer from their offices and get the information they need on each athlete from our database. The way we have it set up, they can retrieve our information, but we can’t get theirs. That way, they don’t have to worry about a student logging onto our computer and finding out details on their patients.

“Before, I was faxing the provider the claim form every time we had an injury that went out to them, or when a doctor saw an athlete here and billed for that visit,” he continues. “This is much easier. I don’t have to fax anything. They just pull the information they need off the computer and it’s all done.”


INSURANCE COMPANIES
Ultimately, the whole tedious process is driven by the varying demands of the insurance companies. And when it comes to jumping though their hoops and overcoming their delay tactics, your most effective response is persistence and documentation.

“Your primary goal is to make sure the insurance company is paying everything that by contract they said they would pay for,” says Kubiet. “And it really all comes down to spending time on the telephone with them.

“Insurance companies and customer service representatives will send you around in these maddening circles, so you really have to keep a good paper trail,” she continues. “I keep a running log of everybody I call, everybody I talk to, and every number I’m referred to. Once I call the customer service representative and say, ‘I called at 2:15 on September 8th and spoke with Allen in Health Services, and Allen told me this,’ and they realize that you have called five or six times and gotten more than one instruction, they’ll usually kick you up to a supervisor level and somebody will step in to resolve the problem.”

It’s also critical to keep documentation on the referrals and pre-certifications you receive approval for. “I don’t have primary care physicians send referrals to the referred doctor’s office,” says Kubiet. “I have them send the referral to me. I keep a copy of it and send a copy with the student’s insurance information to the provider. That way, when all of a sudden the insurance company turns around and says, ‘No. This wasn’t an authorized visit,’ I can say, ‘Oh yes it was. Here’s the referral number. I received this number on this date. And here’s the actual hard copy.’ The better off you are in terms of documentation ahead of the game, the more likely you are to get them to pay for the care.”

In addition, many athletic trainers have discovered that sometimes the best way to avoid lengthy phone sessions to insurers is to sacrifice a little drive time. “A lot of our athletes have HMO coverage out of the Minneapolis area,” says Rudd, “and we have found some providers in the Fargo area, about 75 miles from us, that we can utilize as part of that provider group. So we try to maximize coverage as much as possible by sending student-athletes to the closest in-network physician for their policy.”

“We might drive a half hour versus 20 minutes to find the right provider,” adds Kubiet. “But so what? That extra 10 minutes is all the difference in the world versus an hour fight on the telephone.”

And when it comes to tracking where a claim is with your secondary insurance provider, some departments are looking into obtaining technology that allows them access to their secondary insurer’s claim-status data. “Our university is inquiring about installing a big database that would allow me to tap into our insurance company’s computers and find out the status of our claims,” says Kessler, “Actually, some area health centers already have the technology.”

Ultimately, managing student-athlete insurance claims, locating preferred providers, and ensuring insurance companies aren’t skirting their financial obligations is an extremely time-consuming task. These short-cuts and time-savers may seem small when considered individually, but their cumulative effect can help make this daily responsibility a lot more tolerable.


For a more in-depth look at how Towson State saved on x-ray charges—and all the paperwork involved in filing for claims—see the sidebar accompanying this article on our Web site. Just go to www.athleticsearch.com and search for “insurance.”