Cut through double talk when getting claims paid
Don't be deterred by double talk or vague promises when attempting to get claims paid. Instead, take advantage of all the resources at hand and be assertive. That's the advice from Angie Smith, marketing manager for Resource Recovery Consultants, Arlington, TX, a third-party collections firm.
When the company's "consultants" - the term it uses rather than "collectors" - get an insurance company's customer service representative on the phone, they're trained to ask to speak with someone who can handle the claim right away, Smith says. If told a claim is in process or under medical review, the consultant asks to speak directly with the "medical review department" or "processing department" to get a firm confirmation of what is needed to get the claim paid.
"If we get a claim, and our consultants start calling, and the insurance company says, 'We haven't received it,' we say, 'Let me fax it to you right now,'" Smith says. "If they say they need the medical record, we fax that or send it by certified mail. We paint them into a corner."
Sometimes a bit of ingenuity is needed. "Today, an insurance company called about a claim and needed to know what a particular service was," she says. "Rather than request the medical record - a lengthy process since we'd have to contact the hospital - we looked up [the term] in a medical dictionary. We called them back and said, 'This is what this is, and this is how it relates to the claim.' What could have taken two weeks was resolved right away."
Such creative solutions require a well-trained staff, Smith concedes, noting that her company hires only people who have worked in a hospital or clinic environment and who pass a competency test. The test, which draws from the billing and collections questions on the American Association of Healthcare Administrative Management's certified patient accounts technician (CPAT) exam, also covers basic health care acronyms and asks for responses to various billing scenarios, she adds. Consultants are encouraged to take the CPAT exam as well.
One consultant works on a claim to completion, which means he or she must give a definitive answer on the claim's outcome before moving on to the next claim, Smith explains.
For example, if told a medical record is needed to complete the claim, the consultant makes arrangements for the record to be sent and notes that on the file, indicating that it may be two weeks before the claim is resolved.
Supervisors can follow the notes on the file and determine when payment can be expected, she says. "We give our consultants a manageable number of claims, which allows them to do this. We've found that works better than just calling on a lot of claims, hit or miss."
Because the company doesn't do patient collections, patients are brought into the process only as a last resort when the consultant can't get through to a supervisor. In such cases, patients are asked to call the insurance company directly.
"We call the patients, give them a rundown, say this is what's happening, and now we need you to come in [to the process], too," Smith explains. "Two people are better than one, and if a patient calls and is angry, it holds a little more weight."
The company makes use of certified mail primarily in workers' compensation cases, if it has to file an appeal. In selective cases, however, the company extends the idea to other situations, Smith says. One such case might be if the company is processing a $25,000 claim and wants to make sure the insurer receives it. Collections departments might set their own thresholds, she suggests, based on the numbers for their facilities.
Smith, who says her company has worked with more than 150 hospitals on their claims collection efforts, has another piece of advice for hospital billing and collections departments: "Once you do get paid, review the payment against your facility's contract with the managed care company, or in the case of a workers' compensation claim, against the fee schedule."
"Make sure what you were supposed to be paid is what you were actually paid," she says. "In Texas, about one in 15 workers' comp claims are paid incorrectly." The figure is even higher in other areas of the country, she adds, and the problem extends to managed care companies, too.
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