Conspiracy or Nah: Claims Consistently off a Few Pennies on Payment

Client Kelly Doe went to treatment. Medical necessity was met but it had to go to review to get approved. Claims magically got lost. After 4 follow up calls and 2 months later, claims finally paid. Although paying at an embarrassingly low rate, 2 of the 4 RTC claims paid correctly. The other 2? Mysteriously short on $.12. A measly dime and two pennies.  

So how can you ensure you’re staying on top of that $.12? Limiting your Denial Gap and being precise when addressing any correspondence from the insurance company. 

Creating and maintaining a solid process from the Date of Admission until Discharge is only half the battle when dealing with insurance claims. Depending on each individual insurance policy, most treatment programs do not align with the benefits allowed for behavioral health. When this happens, most programs will bill as an Out of Network provider, meaning more hoops and hurdles to get through, and of course ultimately affecting the allowed amounts paid to members.

Typically a facility will start billing at the RTC or PHP Levels of Care, then based on the Treatment Plans involved with the patient and Treatment Team, will step down to lower levels of care like IOP and Routine Outpatient Services. What most don’t realize is the hard work and attention to detail that goes into making each claim from RTC all the way down to ROP get processed smoothly, but it’s not so smooth sometimes. 

The time it takes for things to be updated and processed can take a huge toll of members if they have to come out of pocket to pay for treatment, so every cent is needed to help cover any losses financially members and their families go through. 

A scenario could be something like this. Receiving correspondence on pending claims requesting a correction on the billing or needing updated clinical, then once re-submitting with everything they requested, it finally gets paid, but at a lower allowed amount then you’re used to. Frustrating, right? It was the same level of care for the same amounts billed, but why do they not pay the same?

There are many factors why this could be. It can be a simple processing error, in which case needs to be sent back for review, or it can be a billing error and 1 or 2 days did not get billed, however, usually the difference in the paid amounts has to do with the members policy and how in and out of network providers are looked at. In our experience, we have approached it in a way of never giving up and being prompt on requested information needed to complete processing. 

We’ve also found out that having the therapists and nurses assistance when treatment is not deemed medically necessary, and utilizing detailed medical records that cater to the insurance company verbiage and jargon, can definitely help with improving daily rates for the higher levels of care like RTC and PHP.

Of course it is not worth the program to fight for that $.12 amount– however, if an insurance company is doing this to millions of members on millions of claims. We’re talking fractions of a penny, but over time, this adds up to be a lot. Just ask the guys from “Office Space”.

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