Troubleshooting Denials

Troubleshooting General Health Insurance Claim Payment Problems

Sometimes claims are paid effortlessly and other times getting paid can be problematic.  Here are some tips to help troubleshoot difficult claim situations.

1) The claim was sent to the medical group

This is a popular problem and I just received such a notice.  In this first scenario 1) A patient has 2 insurances, one I must bill before the other will actually pay.  I billed the first (aka ‘primary’) and was told that they did me the favor of forwarding the claim to the patient’s medical group, Sharp Healthcare.  Lovely. The provider is NOT a Sharp provider (as many acupuncture providers are not members of HMO Medical Groups) and so the claim could potentially get lost in the abyss.  The first thing to do is to call the medical group and hope that you can get them to just deny the claim.  Please do not send back a letter asking us to get a referral or some other nonsense that won’t actually fly but might give the patient hope and make for confusion.  Once you receive the denial, you can proceed with sending a copy of that along with a bill to the secondary insurance. 

2) Your claim was again forwarded to the medical group (but there’s no OTHER insurance, as in the first scenario)

You didn’t bill the medical group, you thought the patient had a PPO and so you billed the health insurance. The first step is to look at the card again and scrutinize it.  Usually on a card there will be PPO, POS or HMO.  Look at the back of the card, if it says to bill Sharp Medical Group or Mercy Medical Group or another common HMO group in your area, an HMO is involved.  If the card has PPO on it, this should not have happened and should therefore be a mistake.  Call the insurance, tell them that you show the patient has a PPO and to verify this, if so, they made a mistake and to please reprocess the claim.  If the card says POS, remedying this will take some effort.  POS plans have elements of both an HMO and PPO.  If you are not part of the patient’s HMO (the medical group or ASH, you should check these benefits now) you can request the claim to be processed under the PPO benefit.  On the claim when you send it, in box 19 typically, you would say: process through PPO or process through OON (out of network).  You should also highlight this if mailing in a claim to bring attention to it.  When they still don’t see it and send it to the medical group and you get a notice that they did you the favor of forwarding the claim to the medical group, you can then call the insurance and say that you specifically asked for the claim to be processed through the PPO benefit.  Often they will pull up a digital image of the claim and see the note and send the claim back through for reprocessing.  If this is the case, always get a reference # for the call and make yourself a note to follow-up on this, just in case.  If you are part of the patient’s HMO but want to use the PPO portion of the plan (because it typically pays better), you CAN’T.  In a POS situation, if you belong to the HMO it becomes the primary mode of payment, the PPO the second.

3) The claim was applied to the deductible you were told the patient didn’t have

This happens A LOT. Many times you will call and verify a patient’s insurance and be told that there either 1) is NO deductible or 2) there is a deductible, but it’s been satisfied only to receive the EOB with the visit having gone to the deductible!  I wish I had an explanation…this is the lovely operator error scenario that often occurs when you call a foreign country and are mis-quoted benefits.  In the case of the patient having a deductible that was supposedly met already, although you can take your time to call on this, I recommend you don’t.  You should charge the patient, if you are sending a bill to them send a copy of the EOB with it and highlight what went to the deductible.  If the patient has a question about this, have them call.  You have done your due diligence and shouldn’t have to do more.  Very rarely is this a mistake more like it was a mis-quote of benefits during the verification.   Contrary to this, if you were told the patient had no deductible at all, you WILL want to call.  Since subsequent visits will probably also go to the deductible, you want to know this in advance so that you can charge the patient at the time of service and know how much the deductible is.

4) The patient wasn’t eligible at the time services were rendered

This is fairly self-explanatory, clearly the patient’s policy was not in effect when they saw you.  This can be for a couple of reasons, 1) the policy simply terminated (ask the patient if they have new insurance), 2) the patient pays premiums on a month to month basis and they are late so if a claim comes through before the premium payment, the insurance may kick it back.  This scenario doesn’t happen too often but if it does and the patient says, oh I just made my payment, then you can call and ask the insurance to verify this and if so, send the claim back for re-processing.  Sometimes, the patient will have had an employer funded insurance, is no longer working there and has chosen COBRA coverage (the patient continues paying astronomical premiums to continue the coverage they had with their previous employer for a limited amount of time). During this transition, there are often claim hold ups.  Once the COBRA coverage gets worked out and put into place, the claims can be processed, but it may take some time and you may have to call and ask to have your claims re-processed.

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