Navigating Health Insurer Challenges: Tools and Guidance for Foot and Ankle Surgeons
ACFAS understands the administrative hurdles that come with managing private health insurer relationships, from complex contracting to claim denials. As part of its commitment to supporting members, ACFAS offers practical tools and resources to help you protect your practice’s revenue, ensure fair reimbursement, and advocate for appropriate care. The College also represents podiatric foot and ankle surgeons nationally as a founding member of the Specialty Society Insurance Coalition.
Smart Contracting: Tips to Protect Your Practice
Signing a health insurance contract without careful review can have serious financial consequences. Even if a contract seems non-negotiable, it's essential to evaluate whether it aligns with your practice goals.
Before signing a contract, consider:
- Know who you’re dealing with. Research unfamiliar companies, verify whether they are insurers or rental network PPOs, and understand how they operate.
- Evaluate patient volume impact. Will patients follow you out-of-network if you decline the contract? Assess your patient base and long-term relationships.
- Assess fee schedules. Use your billing system to analyze top-billed codes and determine whether proposed rates cover your costs.
- Read the fine print. Insurer policies and procedure manuals—often incorporated by reference—detail requirements for preauthorization, eligibility verification, and appeals.
- Consult legal counsel. An attorney can flag red flags and help you make informed decisions.
- Ask questions. Don’t hesitate to contact the insurer’s provider representative for clarity on contract terms or policies.
Preventing Claims Denials
Claims denials - especially those due to simple errors - can be costly and time-consuming. Filing a "clean claim" the first time reduces the risk of rejection.
Best practices for minimizing denials:
- Double-check all patient demographics, insurance information, CPT/ICD codes, and modifiers.
- Use claims “scrubbing” software or services to catch errors before submission.
- Ensure proper documentation of referrals, surgical notes, and required forms.
- Track denials by reason and payer to identify trends, errors, or systemic issues.
- Be vigilant about coding accuracy, especially with high-complexity E&M levels that may trigger audits.
Appealing Medical Necessity Denials
When a claim is denied as “not medically necessary,” it’s critical to respond with a well-documented appeal. These denials challenge clinical judgment and often require significant documentation to overturn.
Steps for successful appeals:
- Understand the denial. Review the definition of "medical necessity" in your contract and obtain relevant payment policies from the insurer.
- Gather documentation. Highlight aspects of the medical record that justify the procedure. Include surgical reports, labs, imaging, and relevant literature.
- Speak with the reviewer. Maintain a professional, non-adversarial tone. Accredited plans must allow clinical review discussions.
- Prepare a strong written appeal. Include:
- Claim and patient details
- Supporting documentation
- A narrative explaining the clinical rationale, including extenuating circumstances
- Literature supporting the medical necessity
- Submit the appeal properly. Use fax, secure mail, or online portals—and keep a copy with confirmation of receipt.
Use ACFAS’ Sample Written Medical Necessity Appeal as a guide when drafting your response.
Disclaimer: The content provided here does not constitute legal advice. ACFAS members should consult with their legal counsel regarding contracts or appeals.