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 survival skills. 

What I’ve learned:

  1. 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.
  2. 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.  
  3. Clean 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.    
  4. 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. 
  5. Sending 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.
  6. Speaking 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.
  7. Don’t 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.
  8. Don’t assume that all processing data, including fee schedules and payment rates, are updated annually. When in doubt, ask.
  9. Don’t 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.
  10. 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.
  11. 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.

Of 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.


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