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Insurance Claims: Paid, Denied or Disappear Into Thin Air

Is it only your practice? Is anybody doing anything about it? Usually, whatever is happening in your practice is happening all over in your region.

You send in 100 claims to the insurance agency...

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Paid Claims
Would you like to see your “paid claims” number rise – the first time they are submitted? Dealing with insurance companies is part of running your practice. Keep reading – I have outlined specific steps as to how to have less denied claims and to make certain the claims just don’t disappear!

Working the Denials
My work experience has shown me on average 75% of the denials are improper and if you fight you can win about 85% - 90% of the time. But fighting takes proper experience; time to make the calls, write the letters, and to do the research.

Dedicate Time and Staff
If you don’t know how much time you have set aside for your staff to work your accounts, then you should not be surprised when you see your accounts receivable rising.

  • Ask to see the copy letters of appeals your staff has done each week.

  • Go over some of your EOBs and ask your staff questions about what they are doing about your EOBs.

  • How far behind are they at fighting the denials, lack of proper payment?

    • Are they are piled up in a drawer?

    • You should know where they are and should check on what is going on.

  • Whoever you put in charge of your billing follow-up, you should meet with them approximately every 2 weeks for updates and patterns of errors on the practice side (what the practice could do better) and patterns of inappropriate denial from the insurance carriers and which carrier is giving you are hard time. They should have paperwork showing what is being done for your denied claims.

  • Your medical billers should be able to notice trends in what is happening with the insurance carriers.

  • If your staff does not have time or the proper training – call in outside help. This is your money!

Be Ready for New Rules
Many times, once Medicare starts a new rule or policy the other carriers follow, you have to be ready. Make sure your patient registration forms change as needed to gather the data that you need to bill the insurance properly.

Example: Medicare is now requiring if the patient’s Medicare card has a middle name listed, your claim must also have the exact information as seen on the Medicare card. If you only have an initial on your demographic form, then the people who enter your data will only enter the initial and your claim is rejected.

Other insurance carriers might follow this trend and/or implement other requirements, which lead to increasing their revenues - by denying your claims. It may not be this year but I believe there will come a time where the Blue Crosses and Cigna’s and Alliance Products out there will start requiring the full middle name as well.

Electronic Billing
Some people push and sell the idea that using electronic billing will solve all your problems. This is not true. It does help get the claims to the carriers faster and get the claims processed faster. It does not change the number of denials or lack of improper payments. You just find out about them sooner, but many times you need to send a paper claim when appealing for reprocessing correctly. Sending electronic claims alone does not solve the issue of the need for proper review when posting the EOBs and doing your research to make sure the insurance companies “reason” for not paying makes sense.

The electronic submission and completion reports must be reviewed by your staff but most are overwhelmed with just trying to keep up with the daily tasks and don’t have time dedicated to actual follow-up work.

Secret Codes
Did you ever notice how many different numbers, secret codes, letters, and numeral alpha combinations different insurances have for rejecting your claim?

There is a very large carrier in Northern Virginia area that has more reasons to reject a claim than there are days in the year. It seems like 30 of them are saying the same thing (duplicate claim, claim previously processed, claim processed previously, claim already adjudicated, reimbursement has been determined and no other reimbursement due provider)

What Can You Do to Decipher the Codes?
The insurance companies hope that your staff does not have time to follow-up and appeal. They are hoping the person on your staff who posts your insurance explanation of benefits (EOB) will just do what the insurance company says, adjust it all off or bill the patient for the full amount. In many cases, both these decisions may be wrong. You cannot always believe the EOBs.

It seems that your staff are not always receiving all of the explanation of benefits that insurance carriers are sending out. You have to research each claim situation. If you don’t - your practice will continue to loose more money. You must take control.

What if the Medicare code says CO18?
It means ‘duplicate claim/previously processed”

  • Upon researching the actual claim/patient account half of the time, however, the account is still left unpaid.

  • So you have to call Medicare and find out what action they took when they processed your claim.

  • In some cases checks are sent to other doctors, some checks are sent to the patient.

  • It is rare, but there have been cases where employees of the insurance carriers are improperly handling insurance checks. They say the claim has been paid, and a check has been issued. But when you press for a copy of the front and back of the processed check, many times they cannot produce it. Here’s what happens - they make the check out to the patient but then they have someone else deposit or cash the check.
    So neither you nor the patient get the check and they keep telling you “duplicate claim” or “already paid”. In which case you have to press them to pay you right away for your clean claim and/or they pay you interest on the check.

  • Always keep track of the name, date, and time you spoke to an insurance representative for future issues. In case it turns into a legal situation, you have detailed notes, days, and times of what has happened.

  • It could take from 2-4 contacts with the insurance company to come to a resolution for each claim so it is very important to have the names and dates written down as ammunition to help you win.

Claims that Disappear into Thin Air

When I call other doctor’s billing people and ask them are you having trouble with certain large insurance carriers withholding payments for no reason, they say YES.

This can happen for many reasons such as:

  • The insurance carrier is getting ready to put out a new insurance product

  • The insurance carrier is getting ready to buy or merge with another

  • The first quarter of the year (January through March, notice pattern of 90 days/3 months) because of the new deductibles

  • Coordination of Benefits (COB)* can cause problems so many practices find lower reimbursement during the first quarter.

*COB is when the insurance carrier requires each patient to fill out a form or to call to verify that the insurance company is truly going to be the one to pay primary for this patient. All carriers do this to just about all patients.

COB issues happen each year – but you can avoid them
Most patients ignore the COB forms that come from their insurance company at the beginning of the year. But, this directly affects your bottom line as the insurance companies use this as an excuse to withhold money from physicians at the beginning of the year.

This will be more work for your staff BUT you will see your accounts receivables decreased by these actions. Have them work it into their routine – it will pay off! (And then take bring in a nice lunch at the beginning of April to celebrate!)

Start in December and continue until March

  • No exceptions - do this for all new and existing patients.

  • Keep track so you don’t ask the same patient over and over again.

  • Print out a demographic form, have the patient review, update and sign it before they see the Doctor.

  • At the end of each day, send the forms to the insurance carriers and be certain you keep a copy for your files.

About EYE Bill FOR YOU

Based in Maryland with over 20 years of experience and a broad range of medical billing knowledge, EYE Bill For You offers HIPAA compliant medical billing for many specialties. Our medical billing outsourcing solution is offered in Virginia, Washington DC and Maryland.

Catherine Boddie (owner) has an established reputation for helping doctors lower their accounts receivables by examining super-bills and improving them to increase reimbursement levels. Catherine has taught students in medical billing and coding at Northern Virginia Community. Catherine has provided lectures and training sessions on medical billing and coding, Self Pay Issues, and working with Embassies accounts at Georgetown University Hospital and Medical Center.


Catherine Boddie, President
email: cathy@eyebillforyou.com

For permission to republish the above article, please contact Catherine Boddie.

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