COLLECTION
The purpose of collection is to find out what happened to the Dr’s money. Why is the claim not paid? What can we do to get a payment? You need to try and act as completely as possible: try to make sure that the actions you are performing will facilitate either a payment or finalization of the claim. The point is not to keep the claim open.
There are three areas of collection.
Rejected – These are the claims that have not left the clearing house. If you fix it DO NOT send it as a correction (frequency code 7 is ONLY for claims that have made it to the insurance and have an assigned claim number!)
Denied – These are the claims that the insurance has processed and either partially or completely denied. If it is completely denied it may be an eligibility issue or the wrong Dr.
Eligibility – the patient may have a new ID with the same plan or an entirely new policy with a different plan. Check any EMR software available, check the superbills, check the patient’s account we may have some other policies on file that can be active again.
Dr. – The Dr. could be out of network with the plan so ask what plan it is if that is the case. Let the supervisor and Enrollment dept. know. It may be that the PCP is different: If it is a Dr. from the same office you can try to send the claim for review as the tax ID is the same. Or it may be an entirely different doctor from a different office in which case we will need to place the claim on HOLD to let the office know that the patient needs to backdate the PCP or to let the office know that they will not get paid for this claim since backdating isn’t always an option.
Untouched – Are claims that were either sent to an insurance and we never received a response (whether it paid or denied or got rejected) or they were worked on and are due for a follow up. Most insurances ask for a minimum of 30 days. There are others like Fidelis that usually complete an inquiry within 7-10 business days.
When collecting, if we can not finalize a claim we need to leave as concise a comment as possible; you may not be the one to follow up and the person after you needs to know what happened so they are not starting from the beginning and losing time. We need to be thorough. Make sure to take down the name of the person you spoke to and a reference number. If there is no reference number get a last name initial.
Did the claim pay COMPLETELY OR PARTIALLY? Why did the procedures that denied not pay?
What is date on the check?
What is the check number?
What is the full amount on the check (if it was not a single check)
What address was it sent to?
Can they see if it cleared (was cashed)? If not then we need to request a duplicate payment.
Can they fax it?
If the claim did not pay – What was wrong with it? What can we do to fix it? What is the difference between how this claim processed and another for the same patient if the other claim paid? Where do we send a correction? Where do we send a reconsideration? Where do we send an appeal? Can we fax it? What is the timely limitation for sending a correction/reconsideration/appeal.
PAY ATTENTION TO TIMELY FILING.
If the insurance can not give you an explanation of a denial then it is very likely in error. Do not let them convince you that you need to send a correction. If there is nothing wrong with the claim then it is an internal issue and they need to reprocess it. If we send a correction then it will deny as a duplicate. Only send a correction if there is factually something to correct on the claim. How to check: you can run a report for a certain procedure and see if it is payable by the plan. Especially for the same patient! Or for another patient but within the same month.
When a phone conversation does not solve the problem.
We can either send a correction- if the information is not correct i.e: the patient ID, the name, DOB.. or any of the Doctor’s information (its possible the agreement is to bill under the group information instead of individual doctor.)
We can send a reconsideration – asking the plan to re-think the denial and sending any valid information (if the claim denied for timely, do we have any proof that it was sent on time? Was it sent to a different insurance? Did it get rejected by the clearing house report (can send the report), did it get lost in the mail 9send proof of mailing) Did something deny as not medically necessary? Send medical records.
We can send an appeal – usually a different department entirely which independently reviews all the information. This is most often a last chance at payment and if done on time can work in getting the Doctor paid.