Case Study: Getting Claims Paid

As a medical billing/management company, we are given the task to follow up with insurance companies to get the claims paid for any charges turned in to us. Some insurances - like Medicare - make that task easy by having strict regulations in place that we follow and, by doing so, they pay easily and on time. Others will loosely follow guidelines and hold or even deny the same claims, and we are forced to contact them to get that claim paid. Find out how we help get those claims paid.

On-line access with most is marginal at best and does not give out any more information than the denial did. Some have a dispute option you can file to argue that their denial was unjust and that can then be overturned. If there is no on-line feature, you are encouraged (meaning you have to) call them and speak directly to an agent. Hold times since the pandemic have increased dramatically to as much as 120 minutes (2 hours with bad hold music) and then you can only review 2-3 claims with them and they would need to call back again! If you are so lucky as to get through, getting transferred from there to another rep just makes the whole process even more enjoyable.

There are times this whole process is so worth it to get the provider paid for their services rendered and have the insurance company pay the benefits that the patient pays premiums for in the first place. We have appealed many claims and received payments for large amounts of money and did a little "happy dance" at our desks when it comes through. I have sent out a lot of "atta girls" and "atta boys" to my staff to celebrate. Our company charges by a percentage of collections so if the provider does not get paid, we don't get paid so that's motivating,

Some examples of success stories:

1. Appealed Neuro Psych Testing cases more times than I can count to get the medical group to pay instead of the health plan (yes they are different and the contract states who is responsible for these). Paid!
2. Learned how to bill a new Procedure that the insurances had not really known about and educated the claim reps on who it is being billed and got them to pay them. Success!
3. Instructed claim reps that if a provider is not contracted with an insurance, to not forward claims to the carve out and go back and reprocess the claims - Win!
4. Signed up for on-line claims with a federal program with 2-step verification with my SS, DOB and blood type to be able to login and retrieve payment details to post into our system. Still B+ each time I log in!
5. Had a client move out of state and signed up for new insurances I had not worked with before and got everything working smoothly. Easy!
6. Worked repeatedly with a small insurance company that now knows my rep by her first name and knows which accounts she is calling on by name and yes, they will reprocess the claims and send out a paper check soon. Cool!
7. Signed up with the most difficult insurance company in my 30 years of billing and had to re-write the billing script with my engineer to meet their requirements and can now bill and get paid every month (this one was a personal quest). They did not beat me!
8. Set up systems to fax over claims to a payor that insists on hand filled out forms only to go with each claim to get them paid. Faxes for everyone!
9. Worked with Federal Prisoner payers to determine the right inmate ID, authorization and correct arresting agency before even billing out the claim. Feds rock!
10. Continue to work with a local County contract and make adjustments to their coding and modifiers as needed. Telehealth added a whole new set of rules for us to follow and adjust to "per payer" to signify a service was done by Telehealth. The fun never ends!!