The Troubles of Billing in a Medical Office Part II

So, as I outlined in Part I, you sent out your claim to the dozens of insurers your patients are part of.  Here is only 10 ways out of a million your claim can be denied.  The reasons below are so bad, you are tempted to do this:

Pay Up or We'll Shoot Max!!

1. You put in the wrong member ID.  Generally, the member IDs are no less than 10 digits mixed together with letters, and sometimes with special characters -- which the computer databases often do not recognize.  Years ago, there was an insurance company called _____ which had -- I kid you not -- member ids that would include % or #.  Many staff members who did billing likely ended up cross-eyed or committed suicide.  I decided to shoot a dog...Imagine if you had to type something like that over and over again every day.  That insurer should have been sued for everything under the sun. It was sued numerous times and still exists with different entities and different names and continues to make a bundle because it never pays any claims.  How can it when the member ID numbers are wrong?  Get it right and they will pay.

2. Wrong codes.  There are 68,000 ICD-10-CM codes and 87,000 ICD-10-PCS codes  and nearly 8,800 CPT codes that must be connected to the ICD-10 codes.  Oh, the ICD-10 codes are new ones being implemented this year and replacing the ICD-9 codes that had been used for over a decade.  You put in the wrong code or combination of codes and you get denied.

3. Wrong patient info. You put in wrong patient info, say an outdated address that only the insurer would know, but they will not tell you the new address because you have to get that from the patient.  Patient confidentiality man!  They can't violate that even it means they don't pay, and especially if it means they don't pay.

4. Prior authorization.  Dr. works like crazy to treat a patient and spends hours to get to the root of the problem because he walked into your office all pale and sick.  And being a doctor who can't by law deny care or you get sued, Dr. does it.  Then he claims for payment and the insurer says he didn't prior authorization.  Nothing you did is worth any value to the insurer. Sure the patient feels great, but too bad if you, the doctor, feels bad.

5. Termination of coverage. Even worse is when you treat a patient and then when you call to claim, he didn't have coverage.  the insurance card he showed had expired.  Too bad.  You get denied.

6.  Excluded or non-covered services.  You as the doctor did all you could, including an extended diagnosis, etc., but you come to find out that the services you provided were excluded or non-covered. You get denied.

7. Request for Medical Records.  You did everything you could and the insurer is valid, etc. Then, the hammer drops because some health insurance plans may require medical records when the claim requires further documentation in order to adjudicate the claim. The medical record includes but not limited to the following:  Patient medical history,

Patient physical reports, Physician consultation reports, Patient discharge summaries, 

Radiology reports, Operative reports.  That would be hours of your staff time, postage, copying, etc. only to be denied later after you've submitted it.

8.  Coordination of Benefits.  Another sneaky way is Coordination of benefit denials  which could include:  Other insurance is primary, Missing EOB, Member has not updated insurer with other insurance information. Coordination of benefits is a term used when a patient has two or more health insurance plans. Certain rules apply to determine which health insurance plan pays primary, secondary or tertiary. There are several guidelines to determine in what order the medical office must bill each health insurance plan and those guidelines are designed to keep taking you around in circles....

9. Bill liability carrier.  If the claim has been coded as an auto or work-related accident, some carriers will refuse to pay until the auto or worker’s compensation carrier has been billed. For accident related services, the following third party liability insurance should always be filed as primary, not the insurance company:  Motor Vehicle or Auto Insurance including no fault, policy or Med Pay, Worker's Compensation Insurance, Home Owner's Insurance, Malpractice Insurance, Business Liability Insurance.

10.  Timely filing:  Be aware of timely filing deadlines for each insurance carrier. You snooze you lose. Each carrier's deadline, however, are usually different! So you are on different schedules for each of the companies.