The Secret to Getting Reimbursed Quicker – Claims Follow Up

The Secrets to Claims Follow Up

First things first… “Hello Mr. Insurance Company, I need…”

Speedy resolution of your behavioral health facility claims all depends on effective collections follow up. Follow up on all claims should begin as soon as 7 to 10 days after your claim has been submitted to the insurance company.  Pursuing to get claims paid immediately will not only reduce the time you spend on accounts receivable but will also increase cash flow.

A staff well trained in insurance reimbursement protocols as well as negotiating and customer service is imperative in order to have the most efficient revenue cycle management possible. A key indicator of a competent staff is the ability to have crossover expertise in verifying of benefits, claims submissions

Always be well prepared. Research the patient’s account thoroughly to ensure you’re asking the proper questions. You’ll want to have all the information that you will need at your disposal once you get a insurance representative on the phone. Key notes are things like:

  • Date of birth (DOB)
  • Address
  • Policy number
  • Dates of service (DOS)
  • Amounts billed, etc.

It is very important to get as much as information for documentation from the call as possible. Ask the customer service representatives (CSR) information once the call is complete:

  • Name
  • Extension number (some companies use an employee id number),
  • Call reference number

This is critical when making follow up calls on situations that may take more than one call.

But when you can, try to get this information upfront – often times there are random disconnections from the carrier side. Obviously it is easier to pick up where the last call was ended if there is some reference to start from.

The “Ten Commandments of Insurance Billing Questions”

The ultimate objective is to find out if a claim has been processed and if a payment can be expected. A key indicator that there could be a problem is that it has been over a month since a claim was submitted. If this is the case, the CSR should be able to outline what happened and how to rectify the situation in order to get the claim processed. Be sure you are asking enough questions of the right questions. Doing this on every call and you get closer to obtaining payment from the insurance company. I call this the, “Ten Commandments of Insurance Billing Questions.”

  • Can I get an on-shore representative (OSR)?
  • What is the expected payment date?
  • Is the claim through the clearing house, at the payor, in processing?
  • What is the expected allowable amount?
  • What’s all the information on the payment including the check number?
  • Is there an issue with the claim or what is the reason for the lengthy reimbursement process?
  • Why is the claim still processing or “under review” – what are they reviewing?
  • Can I email or fax medical records or do they need to be mailed?
  • Can this claim be expedited – can I speak with a manager?
  • Why is the claim paying so little, is there an issue with pricing?

This is just like anything else in life – you may not be getting the truth. Advocate!

Customer support for most carriers have call time frame quotas that they try to maintain. They will try to get off the phone as soon as they can without prompting you to gather important information from them. You have to be proactive and assertive with your efforts on these claim calls. Make sure you get all the information you called for, and if something is not making sense, hold them accountable to find the answer or get a manager on the line who can.

An example of this is when a claim payment is being delayed or withheld and the customer service representative does know why, or gives you a very invalid reason for it. They will then just send the claim back in for “reprocessing” or send an “inquiry” in on it. This is not sufficient enough because they will then tell you to check back in 30 days to make sure it processed. Obviously no one wants to wait another 30 days to receive reimbursement.

Do not take “no” for answer. Get a manager or supervisor on the phone who can tell you exactly what happened and how it will be rectified.

When you do finally get someone on the line who has some answers, dig deeper. Make sure there are no irregularities with any other claims or payments that may delay the process.

Remember these people you are talking to are just regular people with regular jobs. Do you best to be kind and empathetic while also being assertive. If you can build some understanding and rapport on both sides, often times they will be able to go the extra mile and break their internal protocols to help you out.

What is Next? Well this is where you make it happen!

So step one is done and you have the information needed on the status of the claim to figure out how to proceed from there. The “mess-up” the carrier has done in order to slow down the reimbursement process will determine your next move.

The absolute first check point is to make sure there is an active policy and there were in fact benefits available. Submitting claims without that is a complete waste of time.

    • Claim did not make it through the clearing house and there is nothing in the system.
    • Lack of clinical information – medical records missing.
    • Coordination of Benefits (COB) is needed on the primary insurance plan.
    • Missing demographic or ID information missing from member.
    • Prior authorization is missing or was not obtained upfront.
    • A Referral from a Doctor did not get submitted.
    • Random lack or wrong Information on claim.
    • Medical necessity for RTC level of care is not meeting the criteria of the plan.

Well you may need information or help from the patient?

Patients are trying to get better at this point, it is difficult enough with everything going on to truly make themselves the only priority. Unless you have no other option, don’t go this route.

Here are a few ways to handle this step:

  • Billing the patient or family directly. If you are not able to get anywhere with the insurance carrier as a provider, sometimes the member will have much better luck. Insurance companies offer different customer support (usually more robust) to members compared to the provider side. You can send the bill to them and they can submit it themselves.
  • Have a conversation with the patient on how to self-advocate. If claims are being held up or not paid or denied out right when they should be paying, you can ask the member to call in and attempt to get answers. Give them call dates, billed amounts, reference numbers, and documentation if needed so they can have a more streamlined call. Also give them a heads up on hoops they will have to jump through and some of the tricks to getting the right person on the phone (managers in the US!)
  • Get the patient on a call and then call the insurance provider. Insurance carriers do the best they can and they have multiple systems and customer support departments that all have to interact. Sometimes the member side and the provider side will get contradicting information. There is nothing wrong with getting everyone on the call at the same time and sorting things out.

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