Originally published February 12, 2017. Payer rules change; confirm current CMS and payer requirements before billing.
The purpose of collection is to find out what happened to the doctor's money. Why wasn't the claim paid, and what can we do to get it paid? Every action should move the claim toward payment or a final resolution. The point is not to keep the claim open.
The three areas of collection
Rejected: claims that never left the clearinghouse. When you fix one, do not send it as a correction. Frequency code 7 is only for claims that reached the payer and have a claim number.
Denied: claims the payer processed and partly or fully denied. A full denial is often an eligibility or provider issue.
- Eligibility: the patient may have a new ID with the same plan, or a new policy with a different plan. Check the EMR, the superbills and the patient's account for other policies that may be active.
- Provider: the doctor may be out of network, so ask which plan it is and tell the supervisor and enrollment team. Or the patient's PCP may be different. If the PCP is in the same office, you can send the claim for review since the tax ID is the same. If it's a different office, hold the claim and let the office know the patient needs to backdate the PCP change, or that the claim won't be paid, since backdating isn't always possible.
Untouched: claims sent to a payer with no response yet, or claims already worked that are due for follow-up. Most payers ask for at least 30 days. Some, like Fidelis, usually complete an inquiry in 7–10 business days.
Leave clear notes
If you can't resolve a claim, leave a short, clear note. Someone else may do the next follow-up and shouldn't have to start over. Always record the name of the person you spoke to and a reference number. If there's no reference number, get their last initial.
If the claim paid
- Did it pay fully or partly? Why didn't the denied lines pay?
- What is the check date and check number?
- What is the full check amount, if it covered more than one claim?
- What address was it sent to?
- Has the check cleared? If not, request a reissue.
- Can they fax a copy?
If the claim didn't pay
- What was wrong with it, and what can we do to fix it?
- How did it process differently from another claim for the same patient that paid?
- Where do we send a correction, reconsideration or appeal? Can we fax it?
- What is the deadline for each?
Pay attention to timely filing.
If the payer can't explain a denial, it's very likely a payer error. Don't let them talk you into sending a correction. If nothing is wrong with the claim, it's an internal issue and they need to reprocess it; a correction would just deny as a duplicate. Only send a correction when something on the claim is actually wrong. To check, run a report for the same procedure and see whether the plan paid it, especially for the same patient or another patient in the same month.
When a phone call doesn't solve it
- Correction: when information on the claim is wrong, such as patient ID, name, date of birth, or the doctor's information (for example, the contract may require billing under the group instead of the individual).
- Reconsideration: ask the plan to review the denial and include supporting information. For a timely filing denial, include proof it was sent on time: a clearinghouse report, proof it went to another payer, or proof of mailing. For a medical necessity denial, send medical records.
- Appeal: usually handled by a separate department that reviews everything independently. It's often the last chance at payment, and when filed on time it can get the doctor paid.