Get Your Medical Claims Paid
Posted by Mitch Mitchell on Mar 17, 2017
Years ago I read a news story titled “The Check Is Not In The Mail”. It was a fascinating story about a health care organization called Athenahealth that did a brief study on how the nation’s seven biggest health insurers pay their bills. What they found wasn’t shocking to anyone who’s ever had to try to collect on hospital or physician’s bills for a living.
They had incidences of companies saying they didn’t have copies of their bills, even when the provider had a signed copy of a registered receipt. They had insurers telling them that they were limited to only so many questions per phone call. I’ve dealt with many of these issues over the years.
The story also talked about some of the excuses payers give in delaying the payment of claims, and how it ends up costing providers in time and expenses on the back end, with most of the costs being passed along to the patients. It mentioned that at least 40% of the denials can be tracked directly back to poor or incorrect information being sent by the providers; that’s a statistic that drastically has to change for health care providers, especially in today’s world where proper information can get claims paid faster.
What also wasn’t particularly surprising was how quickly representatives of all the insurance companies were to dismiss the findings as unscientific, while also claiming just how proficient they really are, based on the number of claims they have to process on a regular basis. I remember having local insurance companies state that all claims are processed timely, and that there’s no reason to ever have to call an insurance company because all will be handled in a timely manner; yeah, right!
The real world doesn’t work like that, as most of us know. We have valid reasons for picking up the phone and calling insurance companies to ask them where our payments are. When I see someone touting that they average time for paying claims is 30 days, I’m reminded of the fact that average means there are some claims that ultimately take much, much longer, and those are the ones that drive up our days in receivables. I also know that it varies from state to state, so whereas a state like New York says claims must be addressed (that’s an important distinction between being “paid”) within a certain period of time, that rule doesn’t cross state lines all that often.
Outside of providers who net their receivables at the time of billing (which is misleading and dangerous in my opinion), how many of you out there are actually averaging even close to 40 or 45 days in receivables? In all the years I was a patient accounting director, I hit 44 days during one absolutely great stretch that lasted about two months, totally gross receivables, before one of my billing people left to take another job. I wasn’t allowed to replace her for another 4 months after that; it never happened again.
That was with our lag time of six days before dropping bills so medical records could get them coded. Even when things were going well, we had claims that were over 90 days in receivables that had nothing to do with self pay; we even had some claims still sitting out there over 360 days. Is there anyone who can’t identify with that?
Since it’s fairly obvious that the insurers aren’t going to willingly accept any blame for their shortcomings, and, as most management and motivational speakers will say over and over, that one can only change themselves, once again we need to take a look at what the providers can do for themselves to help get their claims paid quicker and easier. The following are some things you should look at, or have verified, to help out.
1. Know your insurance contracts.
Most of us try to learn everything we can about Medicare regulations, but after that things start to fall apart. Every one or two years, there’s a new contract with most insurance companies, and almost always something has changed. Since most of the time your contracts are negotiated by someone who really has no grasp of the billing process, you need to try to find out as much as possible as it regards these contracts.
Each month, the major insurers usually send out some type of bulletin describing changes they expect to see in new bills being submitted. Oftentimes, this information, if read at all, isn’t passed along to the people who are responsible for these claims; that needs to change. Much of the information, old or new, can usually be found on the insurers website, but too often employees are blocked from using the internet at work with worries that they’ll be doing other things instead of working.
On one of my consulting assignments, in discussions with a major state payer, I learned that there was a system error for this particular insurer that had gone on for upwards of two years that very few people in the state knew about, yet it was posted on their website. The error message on the explanation of benefits didn’t allude to where the information could be found, and the people responsible for this insurance company at the hospital I was consulting at never thought about picking up a phone to call and find out what the error message meant. If someone had been monitoring the online directives, or even been allowed to use the internet to access the website, they would have discovered this particular error sooner.
2. Request a review of your charge master, or do it yourself.
It never ceases to amaze me how many charge masters have revenue codes ending in “9”, which designates “other”, or unknown services, instead of the correct revenue code, or even the generic revenue code category. This may be fine for your major insurers if it’s in the contract, but it gives other insurers a good reason to deny or delay payment on your claim.
There are many procedures that need something else to be billed along with it to be considered for payment. Things like not billing anesthesia when you have recovery room charges, not billing an expected C-code item with a procedure, or not billing a pharmaceutical along with an injection, will delay your claims.
Coding an item with an improper revenue code in order to get it paid, while knowing that it’s not exactly proper (as in coding something as a clinic because you’ve contracted clinic payments, but you know it’s not a clinic), is not only improper but fraudulent, and it could get someone fined or jailed. Pleading ignorance may work, but it usually doesn’t. Verifying that your groupings are correct, such as making sure your supplies aren’t coded as procedures and vice versa, is crucial. Making sure that all the services you bill have a price on them won’t hurt either (surprising how often I see that).
3. When reviewing unpaid claims, be thorough when verifying demographic and billing information.
I can’t count how many times my mother had to call the provider of services for my grandmother years ago because they’d put my mother’s name on as guarantor, since she handles all my grandmother’s bills and was always the one making the phone calls. The bills often got denied and had to be rebilled because of that error. Easy things such as the incorrect sex or date of birth are inexcusable, but happen on a regular basis. Verifying primary insurance for a child or someone of Medicare age is critical. Checking active dates of service can save you time and embarrassment.
4. Don’t be afraid to pick up the phone and call someone.
Patient or insurance company, your role is to get your medical claim paid. If you need correct information, or need to find out the reason a claim isn’t paid, sending a letter is the easy way but also takes a lot of time.
In the scenario I mentioned on point number one, the acting supervisor didn’t want to call the insurer, hoping there was another way around the issue, but also wouldn’t let the billing personnel call either. Without calling the insurer, we’d have never had the answers that were needed to correct the billing issue, and I wasn’t about to do what was requested of me without confirmation from the insurer (which I knew was illegal and had confirmed by making that phone call). It’s always better to get it right than to continue getting it wrong; it’s certainly more financially beneficial.
Someone has to step to the plate and be ready to accept responsibility for getting claims paid more timely. If the insurers aren’t going to cop to their part in the process, the least medical billing departments can do is minimize their own errors and lack of proper processes.