Musings From A Former Medical Claims Processor
I started my career as a claim processor,
working for several different health insurance carriers. This experience has
proven to be both a blessing and a curse.
The blessing is that I know what really happens to a claim when it is
submitted to the health carrier for processing and the curse, well… I
know what really happens to a claim when it is submitted to a health carrier
for processing. Having been on both sides of the fence, a former claim
processor and a current claim biller, I’ve developed my own set of billing
- Insurance carriers, auto, life,
property, work comp, health, etc. are in the business of trying not to pay
claims. Yes, I said it. I fully
expect my claim to be reviewed, re-reviewed, scrutinized, delayed, questioned,
pended and/or, denied. I also fully expect it to be paid. I try to cover
all of the possibilities by verifying eligibility, thoroughly reviewing the
benefits, setting my expectation for payment, collecting upfront, handling any
upfront preapprovals or referrals and finally, billing clean and keeping that
claim on my radar until the account is ZERO.
- Insurance carriers know that
providers either lack the in-house talent, are too lazy, are totally clueless,
or simply don’t bother to appeal or dispute underpaid or incorrectly processed
claims. Unless I am tipping my server, I
do not plan to leave one dime on the table.
claim does not mean prompt or accurate payment. If I had a dime for every claim
that was billed perfectly, yet ended up being handled all wrong by the health
carrier, I would have a ton of dimes. Errors occur - so pay attention.
- Be nosy.
Call the carrier or pull the billing manual online at the carrier’s website if
you have any concerns about how to bill or how to correct a claim.
duplicate claims is a no no and it may land you on the carrier’s “suspect
provider list.” Sending a claim over and over simply because it was not paid,
without first calling the carrier to find out the reason, is a time waster. It
also adds to claim backlog.
of backlog ... yes, claim backlog is real and nobody wants to talk about it or
admit to it. The delay may not be on your end at all.
expect the health carrier to go the extra mile to find out the correct plan
holder’s ID number or the patient’s date of birth or gender. Don’t expect them
to forward your claim on to the new billing address, read all of the claim
notes (even if they pertain to your claim) or see if a valid authorization is
on file. It won’t happen, so bill it
right the first time.
assume that all processing data, including fee schedules and payment rates, are
updated annually. When in doubt, ask.
assume that the health carrier is always right, claim processing is usually
taught on job so the person that handled your claim could have days, weeks or
years of experience. Benefits have been quoted wrong and claims have been
processed incorrectly. Don’t be afraid to challenge any payment that just does
not seem right to you. The patient’s benefit booklet can help you determine if
a claim has been handled in accordance with the plan provisions.
- Just like
the hordes of socks that seem to go astray during the wash cycle, this too
seems to happen when submitting paper claims. The billing address is correct,
yet the claims “is not on file” with the health carrier. I have even had health
carrier’s tell me that a claim, submitted electronically, was never received.
Electronic claims are easier to trace, paper not so much. You want prompt
payment and you do not want your patients PHI flowing around for any eyes to
see, so, follow up on all paper claims within a couple weeks of submission just
to make sure the claim is on file.
- Set your
expectations for how every claim should pay and jot it down. When payment comes
in, compare your expectations with reality. It is impossible to know exactly
how a claim will pay, but you should be in the ballpark. Not paid as expected?
Your ego is on the line, so you will need to know how you could have been so
wrong. The result; timely correction and rebilling or maybe just a good lesson
on how to get that claim through the next time.
course, you can use all of these wins to help negotiate for a big bonus.
Note: No health carrier
names are mention so no health carrier’s were harmed during the writing of this
article. This article represents my personal history and experiences only.