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Physician Payments

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I am looking for some expert help. I am currently a student. While in class my professor stated that physicians don't always get paid (by insurance companies) according to contract. I am writing a paper on this issue and I am trying to find out:

1. Why don't they get paid what they are supposed to if they have a contract?
2. What can / do they do?
3. How do they know they didn't get paid according to contract?
4. Is there any kind of software that can recognize this mistake? e.g. billing software

Thank you for all you expert help


sounds like a homework assignment....

   I'm not really sure where your professor is going with that remark.  If a provider is not paid what they are suppose to be paid and it is written in the contract, then they need to contact their provider rep and ask why.  I'm not aware of any billing software that would recognize if a payment wasn't correct specific to a particular contract.  The only way to know that a claim wasn't paid according to the contract is for the person who is reading the eob to recognize it.  They have to know the contract, and understand how to read the eob. 

  As a side note, I personally have not seen this happen very often.  Usually the contracts are loaded into the carriers computer system and claims are automatically processed. 

Good luck with your report.


Thank you. He made the statement in the course of discussing the revenue cycle. He is the COO of a hospital here and said that he had seen where providers (private) did not optimize their payments. He said that "infact, some providers don't even get paid according to contract". His example was something like - A patient comes in to be seen and the doctor does the exam. Pt has illness (A). The doctor submits the claim to the insurance company with everything he did. The insurance company delays the claim for such a long period of time that when they finally do pay the doctor doesn't check to see what he was paid for because he is happy he finally recieved a payment. He said in those instances, the insurance company could not have paid for a lab test or some other service but it might not be caught.

Thank you for your response.

He needs to get a better biller!!!


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