Save Money: Claims Follow Up 101
Nine basic tips will help you recoup money for unpaid claims.
By Brandi Tadlock, CPC, CPC-P, CPMA, CPCO
The No. 1 way to improve your practice’s bottom line is to resolve outstanding claims efficiently and effectively. Keep these tips in mind to take the pain out of claims follow up.
Save time by using payer websites as much as possible to check claim status and eligibility, to search for payment policies and coverage criteria, and to submit claim corrections and appeals.
Determine whether a claim is outstanding. If it has been processed, was it denied? Is payment the patient’s responsibility?
For an outstanding claim, verify whether it has been received. This is a good time to confirm whether the patient’s coverage is still active because some plans can retroactively terminate.
For a claim that has been received, make sure it’s being processed. Get an estimate of when it should be processed, and make sure no additional information (e.g., medical records, info from the patient, an explanation of benefits, etc.) is needed to complete processing.
If the claim was not received, verify the billing address, and then see if the claim can be resubmitted electronically or by fax. When resubmitting to the same address, send the claim by certified mail to ensure you have proof of timely filing—in case it gets “lost” again.
Know your state’s prompt pay laws. Many states, such as Texas, Oklahoma, New York, Ohio, etc., require insurers to either pay or deny claims within 45 days of receiving a “clean claim” (a claim that includes all of the basic information necessary to adjudicate it).
States may also specify time lines in which insurers are legally obligated to provide requested information in writing, such as detailed rationale supporting a denial. For example, in Texas the deadline is 30 days.
Become familiar with the concept of the “mailbox” or “postal” rule, and find out if it’s applicable in your state. This rule presumes that if a claim is mailed to the proper address, it has been received after a specified amount of time (five days, per Texas law).
Establish a process for contacting patients to request information (coordination of benefit updates, for example) on behalf of their insurer. It may help to create a template letter for commonly requested items, which then can be drafted quickly, as necessary. Call the patient to inform him or her that you will be mailing a letter as a reminder. Establish a time limit for patients to respond to your request (e.g., 10 days) and notify them that they will be billed for the full amount of their charges if they fail to follow through. Often, seeing the bill is incentive enough to encourage patients to do their part.
For denied claims, gather as much information about the denial as possible. You need to understand exactly why the charge was denied to find a resolution.
For example, if the denial states “non-covered service,” you should know why it isn’t covered. Is the service always excluded from coverage, or is there something about the way it was billed (e.g., the diagnosis, the patient’s age, etc.) that caused the denial? Is the denial limited to the patient’s group/plan or is it a company-wide coverage policy? If possible, try to locate relevant coverage information in writing to guide you.
Submit corrected claims and appeals within the appeal deadline for each payer. Clearly mark corrected claims and appeals so they are distinguishable from new claim submissions; otherwise, you’ll receive a “duplicate claim” denial.
Keep detailed records of your efforts to follow up on claims, including the names of people you speak with (as well as the contact date and time). Note specific information they relay to you and any actions you take (such as re-filing the claim or verifying eligibility). This will help you to recall information if you need to address the claim again in the future, and it will prevent you from doing the same work twice.
Brandi Tadlock, CPC, CPC-P, CPMA, CPCO, is a member of the Lubbock Lone Star Coders local chapter. She’s been in healthcare for five years, working as a coding and compliance analyst, a medical record auditor, and a reimbursement specialist.