Medical Billing – Claim Payments and Problem Resolution Cases

I have added additional claim problems for our readers, to present the types of denials medical practices deal with every day. Our priority as medical billers is to always transmit a CLEAN CLAIM for quick turnaround of money. The two denials below took close to 25 minutes to appeal, which is a waste of a biller’s valuable time. Once claims are transmitted, billers must follow-up to be sure their claims were received by the payer – NOT just the clearinghouse. When errors such as the ones listed below occur, it takes away from other important aspects of the job and with most carriers enforcing 90 day filing limits, this could create financial distress in a medical practice.

Medical Billing – Claim Payments and Problem Resolution Cases – Part 2

CASE ONE: Kate Martin received services by her provider in the total amount of $363.00. Her payer denied the claim because: A) The alpha prefix in the submitted ID number is not correct for the date of service. Please use our electronic eligibility service to verify the member’s current alpha prefix. Then correct the data and resubmit. You will need to include the subscriber name in the electronic search. The claim showed the patient as having PPP123456789 as the “incorrect” ID#. Our records indicated we billed out with XXX123456789, the “correct” ID#. RESOLUTION:

1) We checked how the patient insurance information was entered in the medical billing software.

2) We proceeded to the electronic medical record and verified patient information and looked at the scanned insurance card on file which was current and scanned on the date of the office visit.

3) We went online to the payer and queried them about the patient name, ID#, and we matched the date of birth. We looked for the correct ID# and the effective date of the coverage with that ID#.

4) Results: The billing software, the EMR, and the insurance company all matched indicating no problem. We had the correct information and billed properly.

5) We looked at how the electronic claim looked on a paper claim by logging into the clearing house to see how the claim transmitted and it transmitted correctly.

6) In certain cases you can try and fix the claim online but the problem with this claim was – there was no mistake made! Our billing department called the insurance carrier and told them what we discovered. They had no explanation as to “why” this claim got kicked out for incorrect alpha prefix. They adjusted the claim while we were on the phone, provided us with a confirmation number, and reprocessed the claim for payment. This type of denial is most frustrating because, as a biller, you feel as if the payer kicked out the claim hoping the charge would be written off instead of appealed.

CASE TWO: Paul Ryan had BCBS coverage for twenty-five years and the billing office had no problem getting paid for services until his visit on December 5, 2013. BCBS denied the claim indicating the patient had OTHER COVERAGE. We checked the EMR and saw that the patient continued to have the same BCBS coverage. No changes were made in the medical record. RESOLUTION:

1) We went online to BCBS to verify Mr. Ryan’s coverage on December 5, 2013.

2) His ID# had changed and there was a notation from BCBS that his coverage was now supplemental to Medicare Part A and Medicare Part B and provided the Medicare ID#.

3) We went online with Medicare and discovered the patient had turned 65 since his last visit.

4) We notified the Practice Manager to update the patient insurance information in the EMR with the effective date.

5) We updated our records and re-filed Mr. Ryan’s claim to Medicare for payment. This denial was due to the front desk not verifying patient information and asking if there were any changes in the patient’s medical record. An occasional oversight like this happens. However, if the billing department receives a lot of denials for terminated insurance or for services that were incurred prior to coverage, the practice manager must assess the front desk operations and monitor the amount of denied claims that are received on a weekly basis. Retraining or hiring new staff would be the resolution.

Know More about Medical Billing

Medical Billing and Coding Training- Accurateness
AAPC – What is Medical Billing?