1. Incorrect patient and subscriber information.
2. Incorrect policy and/or group number.
3. Incorrect EDI number or insurance billed.
4. Patient is no longer eligible for services.
5. An error between claim generation and submission.
In many of these instances the claim will sit waiting for payment and no denied EOB will be sent back. If office staff is waiting on notification from the insurance company before following up on a claim, there are many claims that will fall through the cracks. Each insurance has their own timeline for getting claims processed and issuing payment, as well as their own timely filing rules. It is pertinent that your staff understand how long they have to get that claim into the insurance company’s hands, as well as how long it normally takes for payment. Insurance companies with a short timely filing allowance should always be worked first. If the claim does not get to these companies on the first attempt, claims could still be denied after corrections due to timely filing. With some companies having a timely limit as short as 45 days, working accounts every 30 days may not be satisfactory. We now understand why it is important to locate these “lost claims” quickly.
If the claim has been received by the insurance, but the payment is still pending-it is necessary to find out why. Does the patient need to update Coordination of Benefit information? Was a request for medical documentation made to your office, but never actually received? Claims can be held up with the insurance company, without the physician’s office ever knowing. How do we find out if our claims are pending? Easy, call the insurance. A large part of medical billing is contacting the insurance companies to find out why claims didn’t get paid, or didn’t get paid correctly. If your billing staff is not constantly on the phone-they may not be making calls to follow up claims. Just because the clearinghouse report states a claim was received there is NO guarantee the claim will be processed, or paid.
Once a clean claim is processed by the insurance, and the medical office receives the EOB, it must be analyzed to check that the payment was correct. Most physicians have fee schedules to which they are paid an agreed upon amount by each different insurance that they are contracted with. I have encountered times when even a large insurance company had a “computer malfunction” and paid lower than the fee schedule. When any discrepancy is determined, prompt action needs to be taken by the medical office to contact the insurance company to get the corrected payment. Other problems can include processing a claim with an incorrect copay, or deductible amount. When EOBs show claims were processed differently than what was quoted during the initial insurance verification-billing staff need to contact the insurance to get this taken care of. Mistakenly many physicians say “it is the patient’s own insurance, and their responsibility to call.” While I wholeheartedly believe it is the patient’s responsibility to understand their coverage and contact the insurance if there are discrepancies, how many times does this really happen. In the end, it is the physician’s office that loses out on the proper payment because they are waiting for the patient to “fix” the problem.
At Midwest Medical Billing, we are constantly on the phone. Whether it’s completing insurance verifications on new patients, or calling to check on claims, we are always communicating with the various insurance companies whom our physicians bill to. Phone calls to insurance companies are a big part of RCM. It is highly likely that if your staff is not making multiple phone calls throughout the day, RCM is not being worked in the way required to gain the most revenue for the office. If you have concerns about RCM and your office, please contact us.