Chiropractors make many mistakes, but statistically speaking here are the reasons from the medical billing industry that things go wrong, payments get denied, pending or cause your claims and your money to get held up at the insurance company:
1. Incorrect payment
2. Ignored Modifiers
3. Incorrectly reduced codes
4. Claims in review for an excessive amount of time
5. Coverage issues (pre-existing condition, no coverage, lapse of coverage, no chiro benefits)
6. Insufficient documentation Resolving the Denial or Pending Claim
Before You Freak Out…
Before you get all worked up over the latest denial or goof from the insurance company, you should first check to make sure no claim problems exist on your end. I know YOU may be perfect, but there’s a slight chance that someone ELSE who touched this claim before it hit the insurance company may have screwed it up. Seriously, doc, if the claim is denied for insufficient documentation, make sure you have actually documented the issue correctly.
Resolving the Problem
Secondly, most of these incorrectly denied or pended claims can be resolved over the phone. It is important to document who you spoke with and any reference # you are given, also document the day the issue should be resolved and follow-up. Phone calls will resolve about 60%-80% of your issues.
The other 20%-40% will need a written appeal. Do not give up on these claims! The written appeal is extremely important for two reasons: (1) to show that you made a reasonable effort to resolve the issue. The insurance commissioner or the Office of Personnel Management (OPM) will require a copy of your letter and the payor’s response and (2) a special unit with more experience handle written appeals which may have a more favorable resolution.
Also, by NOT appealing, you are playing right into the hands of the insurance company. They know you won’t usually take the time to appeal so they can confidently deny your claims — whether you deserved it or not! So, foil their plan and appeal!
Appeal Through the Patient
Another approach to appeal is through the patient. These appeals are handled by a completely different department at the insurance company. To handle a patient appeal, simply send the patient a letter to sign giving you permission to address the issue for them; attach their letter to the front of your appeal letter and send it off. Insurance companies may not care about you (they can always get another doctor) but they do care about the patient’s premium checks. So, this method does work if needed, but it is slow.
Forever Pended Claims
We have all received support needed letters that present a delay in payment issue. However, lately, payors are pending a huge amount of claims to verify pre-existing conditions for new enrollees. A written request for the first date of treatment is usually your clue that pre-existing is being verified. Understand that, in most states, pre-existing exclusions typically only apply if the patient has a lapse of coverage; however, the insurance companies never ask this question and are having issues developing an internal workflow. A copy of the effective and term date of the previous payor should resolve this issue. Check with your state insurance commissioner to find out pre-existing clauses in your state. If you have sent all requested support and verified it has been received, do not allow non-payment to exceed 60 days from the date received for any issue you have complied with.
The clock is ticking! Send a notification addressing this issue to your state’s department of finance or insurance commissioner. They will follow-up and the payor will comply within 30 days. Catch More Flies With Sugar Or is it “more bees with honey?” However the saying goes, remember – especially when talking to the insurance company employees – be firm but nice.
Having been in their shoes myself, I will tell you that some of the horror stories you have heard are true. The doctor whose billing manager screams at an insurance employee suddenly finds 6 months and $10,000 worth of claims disappear into the void. Complicated billing issues accompanied by an irate biller somehow are solved by a simple accident that sends your claims into the trash.
An important reminder – when your claims are outstanding for quite a while or are large in amount, it is likely that they are out of the computer system and into human hands. This can be good in the fact that you can now get helpful human intervention on your behalf. However, the mistreated employee can also wreak enough havoc on your claims that they will not be sorted out until the next century.
While Attempting to Tame Your A/R Tiger…
Don’t feed the animal by making silly mistakes! HCFA forms that are incomplete or incorrect waste time and money. Lack of documentation means that it was not done, so fix it before expecting payment. Insurance verification, if done properly, can eliminate many A/R surprises before they ever happen.(You may want to consider my Insurance Verification Power Pack for help in this department).
Knowing what to expect from a payor is half the battle. And when you do have to argue or appeal, be vigilant and firm, but respectful. After all, it is a tiger — and you don’t want it to bite back at you!
Is Your A/R Tiger Out Of Control?
If you are feeling a little nauseous or nervous after reading this article, chances are your Accounts Receivable tiger is either getting a little out of hand or is downright dangerous. Is it possible to have $640,000 in Accounts Receivable? Yes. Is it PROFITABLE — not in most situations! Whether you have $640,000 or $64,000 in Accounts Receivable, the real issue is control. Consider these factors:
* Do you have your A/R situation under control or is it wildly untamed?
* Are your outstanding balances relatively new or are they getting oldy moldy?
* Do you get a sinking feeling when you submit claims to insurance payors knowing that they may take forever to pay or not pay at all?
* Are you certain that you are coding and billing procedures correctly or does it all feel like a guessing game?
* Does your coding let you sleep at night or do you worry that an auditor may come knocking on your door asking for money back?
* Do you feel that you are being adequately reimbursed for the work that you do?
If these questions make you uncertain or uncomfortable, you need to fix your A/R problems immediately! The best first step is to submit a FREE Practice Analysis. I will review your questionnaire at no charge and there’s no obligation to use my services.