Five Ways to Get Claims Paid at Your Medical Practice

Managing insurance accounts receivable (A/R) is certainly a war. Not only do you face battles on the home front in making sure you have all the pertinent information to be able to file the claim, but you fight many battles abroad with the insurance company once the claim goes out the door. Many of these battles center on whether or not the claim even arrived, in addition to the ones you fight over correct payment when the claims are received. There is hope, however, for the battle-weary warriors.

Here is a recap of a typical day and the weapons I use in my war over insurance A/R. Hopefully my fellow soldiers in the trenches will find some useful tips in this post.

• My first weapon is a plan of attack. There are many approaches to working an A/R report, but the plan that has always served me well is to begin with oldest claims first. I work backwards in order of aging buckets in order to keep my report as timely as possible. It is important to remember to work all the way back to the current status and not just get bogged down in the over 90-day claims, so that each claim is worked. I have a mental checklist, which was once written down but now has been burned into my memory. I look first to see the history of the claim. I make sure the claim was actually filed. Then I check claim status on the insurance website. If those first three steps don’t reveal an answer as to why the claim is yet unpaid, I make a call to the insurance company.  

• With the current A/R report printed and my colored pencils sharpened, I sit down to begin the day’s battle. Colored pencils, you ask? Why yes, they are my second weapon in my arsenal. I have used colored pencils for many years as an effective sight tool to help me work through my A/R reports. I created a color-coded system that I could use to mark my report as I worked each claim. When I get to the last claim, I could easily look back at my report and readily identify denial trends and know what checks should be arriving soon. After working through your own A/R a few times, you will get a feel for what problems are the most prominent at your practice. I also find this a useful tool to help condense my findings into a concise bottom-line kind of report for my doctor and manager. If you are not a paper and pencil kind of person, the same color-coding principle also works well in Excel spreadsheets.

• My third weapon is thorough documentation. The old adage is certainly true: "Never documented is never done." This means that without proper documentation you cannot prove something was done. I have received payment on troublesome claims many times before based solely on my thorough documentation proving that certain guidelines were met. Good documentation techniques also serve you well in the area of collecting past due balances, as in a way to combat the ever popular excuse, "but nobody ever told me I owed this."

• Knowledge, both historical and current, is my fourth weapon. Historical knowledge serves the purpose of being able to apply what tactics worked well in previous situations to current problems. Building a reserve of historical knowledge also gives you a higher starting point in solving or avoiding problems.

For example, while working on precerts for breast reduction surgeries, I saw a trend that most insurance companies would deny the request if there was not a letter from another doctor supporting our claim that for breast reduction was medically necessary. So I began to tell all breast reduction patients coming for consult that they needed to first see their PCP or OB/GYN to find out if they felt it was medically necessary and if so, provide us with a letter stating such. My success with breast reduction precerts improved dramatically once utilizing that tactic. Current knowledge includes aspects such as up-to-date fee schedule allowable and the latest CPT and ICD-9 codes. The necessity of having correct current knowledge is self-explanatory.

• My last weapon in this war is follow-up. I follow up on everything I send out, pre-cert requests, claims, appeals, promises to reprocess claims, and past due notices. If you are going to assume that your first request will always garner an appropriate response, you might as well start waving the white flag of surrender now. First requests are so named because a higher percentage of the time, second and even third requests will be needed. I firmly believe that at least one-third of the promises insurance company reps make to provider’s offices over the phone are immediately filed in the shred box as soon as the phone call is over. Not to mention all of the monthly statements which mysteriously never arrive at the patient’s home yet never make it back to the office as mail return.