Handling Patient Complaints—Avoid Compliance Risk

Billers can be on the front line when it comes to patient complaints. “The insurance company was billed incorrectly,” or “the statement was wrong.” But did you know you can identify potential compliance concerns? Let’s look at two examples:

  • Mr. X calls your office and complains that the wrong insurance company was billed. You fix the claim and resend the information. Over the course of the week, you receive several calls just like this and just like you are supposed to do, you make the needed corrections and resubmit the claims.
  • Mrs. J is angry. She is a Medicare patient and is getting a bill for services that were denied. She says no one told her she would be responsible to pay this amount and wants you to follow up with Medicare to see why the claim wasn’t paid. You complete your research and find out Medicare denied the claim as not medically necessary.

In each of these cases, there is a potential compliance risk. In the first case, there seems to be a pattern where the incorrect insurance company is being billed. This is a compliance risk because it could appear that you are trying to receive improper payment from someone. Payers such as Medicare have very specific rules published about when it should be billed as the primary payer, and when it should be billed as the secondary payer. Failure to bill correctly can result in possible investigations.

Certified Professional Coder-Payer CPC-P

In our second example, it does not appear the Advance Beneficiary Notice (ABN) was completed. For Medicare patients, if a service may not be covered, you can only bill the patient or the patient’s secondary insurer if a properly executed ABN is obtained. If you do not get an ABN, you cannot bill the patient or the patient’s other insurance. More information about ABNs can be found on the CMS website at www.cms.gov/bni/.

Taking the time to really listen to patients and identifying the true issue behind their complaints can help you protect your practice from compliance risk. Be alert to potential issues and if you identify any concerns, report them to the person responsible for compliance in your office.


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