How to Work with Payers as a Medical Coding and Billing Associate - dummies

How to Work with Payers as a Medical Coding and Billing Associate

As a medical coder and biller, your primary goal when interacting with payers is simple: Make sure payers show your client the money! Ideally, your billing software and clearinghouse will keep you apprised of the status of claims through reports. The clearinghouse (the agency that relays the claim from the provider to the payer) also generates a batch report that identifies the claims transmitted in each batch.

Occasionally, however, a claim doesn’t process. In that case, you need to talk to a real, live human being to find out why. When calling a payer to follow up on a claim, you are the voice of the healthcare provider, so always act in a professional manner. Remember, being nice gets you better service.

Make note of the representative’s first name (and the first initial of her last name) when you call to follow up on a claim and then use her first name as you talk. After the rep says, “My name is Sue,” you can introduce yourself with, “Hi, Sue. This is John from Provider Smith’s office. How are you doing today?” In the beginning, keep the tone friendly rather than confrontational.

It doesn’t hurt to note the phone number and time of your call either. That way, during subsequent calls, you can use this info to prove that you spoke to someone in the payer’s office; this info comes in especially handy if the payer’s system doesn’t have a record of your call.

Remain patient

Normally, the payer representative is required to get three pieces of identification for both the provider and the patient. In most cases, the representative asks you for the provider’s name and specific information such as Tax Identification Number (TIN) or National Provider’s Identification (NPI) Number. You also need to provide patient name, member identification number, and date of birth.

Asks for this information isn’t a stall tactic on the part of the payer representative. It’s required by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA guarantees that a patient’s privacy is protected, and only those with a need to know are privy to this protected information.

Get the resolution you want

Only after getting through the initial step (proving you have a need to know the patient’s confidential information) are you able to inquire about the specific claim in question. Here are some pointers:

  • If the person with whom you are speaking is unable to assist with your inquiry, ask to be transferred. When you are transferred to a supervisor, don’t cast blame. Describe the issue and the reason you feel that the other person was not providing the resolution you need. Let the supervisor know that you have every confidence that he or she can resolve the issue.

  • If you are still unable to resolve the issue, submit a written request and identify the issue in addition to your expectations. Make sure you also define the contractual obligation that supports your position. After you submit this written request, follow up with a call to make sure that the request was received and forwarded to the correct department for appropriate action.

  • Don’t threaten or accuse. Instead, stand behind the claim in question and your expectations as defined by any contract or state laws with regard to claim processing and payment. Ask the representative to help you identify the reason(s) the claim processed incorrectly or was rejected. Make that person your ally, not your adversary.

Any information the representative gives you on the call is not a guarantee of payment. As always, payment depends on the benefits outlined in the patient’s individual plan.