Claims issues are always very complex and extremely time consuming to resolve. Without an advocate many claims never get processed correctly or at all. Often times employees find these unpaid claims being sent to collections. Because we have been so proactive in bringing outstanding claims issues to the for front, we were asked to speak at several carrier events on ways to improve claims processing procedures. If a claim is denied, it is either the responsibility of the member or provider to rebill the claim or provide further information. Here are a couple of examples of our dedication to resolving claims issues.
We received a call from 2 separate clients both complaining that their MRI’s were denied. When the carrier was contacted, we were told the members were suppose to have had the services preauthorized and since there was no preauthorization on file the charges were ineligible and the responsibility of the member. We had questioned this guideline as we had on record a letter to all members from the carrier that specifically stated that the physicians were responsible to preauthorize these procedures. We forwarded a copy of the letter to the carrier. The letter was reviewed and it was determined that the letter failed to mention that for providers outside the state of NH the preauthorization process was the members responsibility.We were told that the issue would have to be appealed. We appealed the case for both clients writing letters and providing documentation. In addition we called all the providers involved to inform them the claims were being appealed and to hold off sending the claims to collections. The carrier did finally approve all the claims for payment.
These issues took several months to resolve. We personally handled all phone calls, emails, and written correspondence for my clients. The claims ultimately were sent to collections in the process of awaiting the carriers’ payments. We contacted the collections companies for our clients to explain the situation and even had the carrier contact them as well. After many hours of phone calls, all claims were paid satisfactorily.
We had received a call from the CFO stating that the CEO had some prescriptions denied because the pharmacy was not in the network. We contacted the pharmacist to find out if they were in the network. They said they were not because they primarily handled compounding and they did not like the discounts from the carrier. We called the carrier to determine if there was anything we could do to have these prescriptions paid. The carrier made an outreach call to the pharmacist to work on negotiating a contract, but in the mean time it was decided that the prescriptions could be covered, but they would have to be sent in as a paper claim every month. We completed a claim form for our client and also faxed the pharmacist his portion to complete. We then sent the claim to CA to be paid. Each month we completed the paperwork for the CEO so he did not have to.
This was another situation of several lengthy conversations and paperwork. All completed by us to save our client valuable time.
