How to Follow Up on a Medical Billing Appeal - dummies

How to Follow Up on a Medical Billing Appeal

As a medical billing professional, if the appealed claim does not bear fruit in the form of a check, you may need to make a follow up call to check on the status of the check. Just as when you compose the appeal letter, always base your argument or appeal on facts found in contracts, agreements, professional publications, and your resources about medical necessity.

Always have all of the necessary information at hand. You need the provider’s NPI number and/or tax ID number. The payer uses these numbers to verify your identity and that you have a right to make the inquiry. You also need the patient’s ID number, his or her date of birth, the date of service, and the billed amount of the claim.

Fully document all conversations with payers or patients in the patient record. Clearly state what was said and by whom, and get the name of the person with whom you are speaking.

Verify how long resolving the issue will take and set up a tickler system to remind yourself, or your staff, to follow up if that date passes and the issue hasn’t been resolved as promised. Base your timing for the next follow-up call on the feedback from the representative. But always check at least every 30 days on all outstanding claims.

Ask general follow-up questions

When following up with payers, ask the following questions and document the answers in the file:

  • When was the claim received? Don’t assume the claim reached its destination. Within 30 days of initial claims submission, make sure you follow up with the insurance companies to verify that the claim was received and is in process. After the 30-day deadline, the next deadline is 90 days. Any claim that is 90 days old needs to be investigated.

  • Has the claim been assigned a claim number? If so, what is it? Make a note of this number.

  • Is any additional documentation needed to complete the claim processing? If additional information is requested, make arrangements to submit that information. After you send it, follow up in a week or 10 days to make sure that the claim is again in process.

  • What is the anticipated completion date for the processing? Make a note of this date; payment should follow.

  • What is the reference number for this call and the name of the person with whom you’re speaking? This information lets you document all calls going forward.

Questions to ask if the rep tells you that the claim has been paid

If the representative tells you that the claim has been paid, ask these questions:

  • What is the check number?

  • What is the allowed amount of the claim? If the allowed amount is not correct, ask the representative whether the claim can be sent back for correct processing. Repeat the obligation as defined in the contract and restate why the allowance is incorrect.

  • What is the amount of the check?

  • Does the patient have any responsibility for claim payment, such as copay, co-insurance, or unmet deductible?

  • When was the check sent?

  • Where was the check sent?

  • What is the reference number for the call? Document this in the billing software.

Questions to ask when the claim hasn’t been paid as expected

If you are calling because a claim has not paid as expected, note the following:

  • Why the claim processed the way it did.

    If a contract was utilized and pricing was incorrect, notify the representative of the correct obligation according to your records.

  • The claim editing software that was utilized to process the claim.

  • The correct address to send a written appeal. (Also, note the account and keep a copy.)

  • The representative you’re speaking to.