How to Get Prompt Processing of Your Medical Billing Claims - dummies

How to Get Prompt Processing of Your Medical Billing Claims

When processing claims in medical billing, the payer enters the claim into its processing software. What happens next depends on the claim. Claims that are compliant with the provider contract and patient’s plan guidelines are usually paid promptly.

Claims that involve high dollar amounts or that need supporting documentation usually require manual processing. Unlike most claims, which are processed by computers, claims requiring manual processing need to be reviewed by a human. In addition to simply looking at the procedures, the payer reviews the diagnosis and other applicable documentation.

For example, if the provider contract includes a carve-out for, say, implants, then the payer needs to see the invoice(s) and calculate the correct payment for that line. Or if a provider has billed an unlisted code and the contract allows payment for this code, then the payer may need to review additional information to determine which procedure the unlisted code represents. As expected, manual claims processing takes longer.

Each state has an insurance department or commissioner, and any commercial payers who violate state prompt pay laws or contractually obligated payment timelines may be reported to the appropriate official. When this happens, the department investigates the complaint and may take action either by serving notice to the payer that payment must be made immediately or, if necessary, revoking or suspending the payer’s license to do business in that state.

Keep in mind, however, that, even though payers are obligated by contracts to pay claims within a specific time period, that obligation is not enforceable if the provider doesn’t submit the claims correctly or completely.

To pay for services rendered, the payer relies on the claims to be correct and truthful, often using a method called claims matching. When specific services are performed, several providers submit claims for the same patient.

Here’s an example: Say that a patient has a surgery. The surgeon submits a claim; the hospital or facility submits a claim; and the anesthesiologist submits a claim. Each claim is slightly different, of course, because each provider rendered a different service, but the surgeon’s bill, the anesthesiologist’s bill, and the facility’s bill should match — that is, the same procedural codes should be on all three claims.

If you are a facility coder, you are actually breaking compliance rules if you call the physician coder to ask what he or she submitted. Stick to the coding. Both claims are based on the physician documentation, and if you follow coding protocol, the claims should match pretty well.

If the bills don’t match, the payer may request supporting documentation from any or all providers. In addition, if the surgeon and facility each bill for a completely different body part than that submitted on the anesthesia claim, an inquiry will likely occur. (Note: Some payers won’t pay for facility charges or the anesthesia charges until after they’ve reviewed the surgeon’s bill.)

Working together with other providers gets claims paid faster. And that should always be your goal: coding correctly and efficiently to secure accurate and prompt payment for your provider. If additional information is requested from a payer, promptly provide it. Failure to cooperate delays not only your claim but all related claims as well.