Interview with a Claims Processor

Recently two memberes of the coding staff at HealthPro sat down with a longtime employee from the insurance industry, to document what radiology and pathology practices should know to maximize claim payment.

About the Interviewers: Karen Perts is HealthPro’s Director of Business Development and Patient Account Services, and Cheri Brinkman is Account Management Assistant Department Leader.

Demographics – The Quick Fix

Cheri Brinkman, HealthPro Medical Billing: Let’s begin at the top. What’s the easiest thing to fix to reduce claim rejection?

“Lauren,” Former Insurance Claims Processor: Demographics. Demographics. Demographics. Demographics are the initial details that a patient presents when submitting an insurance card. It’s so important that the registration staff ask the right questions. Is your name is the same as on your insurance card? Do you go by Andrew or Andy? Do you have Medicare or Medicare HMO? Do you know what you’ve got? Is it active coverage? Did your procedure need to be precertified? What is your address? Can you please show us your card so we can see what your ID number is and scan the back? Do you have a group number?

From an insurance point of view, demographics are the biggest cause of denials and probably the easiest fix. If you have a clean claim submission the first time you’ve submitted a claim for a patient, usually all of the claims that follow suit are going to get paid. So doing it right the first time is important.

QUICK TIP: Double-check your data. Just one typo (e.g. a transposed ID number) can result in denial.


Two Common Paperwork Problems

Karen Perts, HealthPro Medical Billing: Paperwork problems originate at the reception desk. How are those handled?

Lauren: When I worked in insurance, the software that was built into our claims processing basically did the work for us and most denials would be identified by system automation. The two most common paperwork problems were incorrect group numbers, and diagnosis-related errors.

Cheri: Can you give an example of a common diagnosis-related error?

Lauren: Well, for instance, you may have a situation at the office where there’s a female patient, over 40, presenting a second or a third time for a mammogram. But if the diagnosis by the physician doesn’t state that this extra mammogram was required, it’s just an automatic denial.

Cheri: You also mentioned group numbers.

Lauren: Absolutely. We saw this denial all the time. For example, a patient presents to have a procedure done, they hand over their card – they think they’re giving the most updated version – but, in fact, behind the scenes with their employer they’ve had a plan change, so they don’t have the new card. The impetus falls upon the reception staff to always make sure to copy both sides of the card, and maybe even do a preliminary call. Many facilities don’t have the hours and the time with their staff to do this, but I do believe that a quick insurance call to ensure that the patient’s covered can make all the difference.

QUICK TIP: 9 out of 10 denied claims that have incorrect insurance can be resolved if the front desk/registration specialist can look at the front and back of an insurance card.

Preventing Administrative Errors

Karen: How can radiologists and practice managers prevent errors on their own end?

Lauren: Acknowledging your administrative staff is a really good start. Sometimes a radiologist has all these people working for him and he doesn’t even know their names or he doesn’t say good morning. He just walks on by. I know most radiologists work behind the scenes, but if they see staff in the hall they should acknowledge them and say, “You’re doing a good job” or “Keep up the good work” and, in particular, “Thank you for your hard work.”

Cheri: Proper training is important too.

Lauren: Absolutely. I advise practice managers to implement regular training seminars or pair newbies with older, more experienced members of staff. New hires don’t have the background to know the things they need to ask for at the get-go so claims don’t get denied. And, I’ll say it again, champion your employees and appreciate them for their knowledge. Your staff will be happy and your practice will be more successful.

QUICK TIP: Create regular training seminars or mentorship programs to help new hires get up to speed on policy and procedures.

Building a Relationship with Registration Staff

Lauren: It’s incredibly important for a radiologist to have a good relationship with the registration staff at the hospital – these folks’ attention to detail will aid in getting claims paid at the get-go.

Cheri: We don’t work directly with a lot of the front line people in registration, but I know we work closely with radiology managers at the hospital, and there’s practically nothing I wouldn’t do to make that person my friend. We have sent them candy, you name it. These people are very important. Once you’ve built that relationship up with them, they’re going to help you out in any situation.

Karen: This relationship is so important for error-free claims. The registration process at the hospital is only as good as the quality assurance behind it.

Cheri: If they aren’t doing it correctly, the radiologist should begin to notice it on his reporting. A billing company cannot directly address a problem with an outside facility, but the practice manager can. That’s why the practice manager needs to be informed of the situation and to work with the registration staff to resolve the issue. They’re going to be much more helpful if you’ve treated them well from the start.

QUICK TIP: A strong relationship with hospital registration staff will pay off in error-free claims.


Importance of Timely Filing

Lauren: If you’re a preferred provider who is contracted through their networks, you normally have 365 days to file a claim. That may not be true if claims are filed electronically; that’s usually a 90-day window. Some payors now demand 60 days.

Medicare is much more strict, especially if you’ve got a secondary payor that Medicare needs to transfer the claim over to so that the patient doesn’t get balance bills.

Karen: Knowing those numbers is key. It’s in every radiologist’s best interest to partner with their billing department and/or to research their own contracts, to know what their timely is for each of their payors, especially those payors that contribute to the majority of their reimbursement.

Cheri: In general, if you can get the claim out the door timely and it’s clean, you’re going to get paid. But if there’s an error that you cannot prevent and it gets denied, the billing company has to be very aware of the timely filing guidelines.

Karen: It’s every radiologist’s right and responsibility, whether they use a billing company or not, to hold those people that do their billing accountable to getting their claim submitted in a timely matter, so there’s not a timely filing write-off situation. And then it’s every physician’s right to also hold their contracted insurance company accountable to paying those claims within the prompt pay period.

QUICK TIP: Billing 101 is to get your claims out in a timely manner.


Karen: If a precertification is done incorrectly or not done at all, it will almost always result in a denial – and most of those denials can’t be appealed. For example, let’s say a patient is ordered to have a procedure and the ordering doctor doesn’t contact the insurance company to precertify it. When the patient presents at the hospital with no precert, the radiologist and the hospital end up doing that procedure for free.

Cheri: We consider radiologists to be blind providers – they are totally dependent upon the facility and the ordering doctor – but they need to be aware of:

  • How the hospital handles this situation
  • The guidelines if the ordering doctor has not done the precertification
  • What procedures are necessary in their eyes to be precertified

As a billing company, anytime we get a denial on a precertification, we call the facility and try to verify the details. We also provide a reporting function so radiologists know if items were written off because of a precert. Within that report, it’s indicated who the ordering doctor is, so the radiologist can know if one particular office is not obtaining precerts.

Karen: Any good billing company is going to have an audit trail of reports that should allow a radiologist to track these kinds of details back and talk to the referring physicians.

QUICK TIP: Educate your patients every time they present at reception – no matter what the facility – to know if precertification is required.

ABN Forms

Lauren: ABNs, for the most part, are important for a freestanding imaging center. An ABN allows a billing department to bill the patient directly if the insurance company denies it. Let’s say a patient presents with no other history on file – for example, you can’t look them up on the computer to see when their last mammogram was.

  • If a patient has Medicare and they have a mammogram, Medicare is only going to pay one mammogram per calendar year, 365 days.
  • If it’s 364 days, they will deny it and you cannot bill the patient.

However, if the patient signs an ABN, they become responsible for knowing when they had their last mammogram and they’re responsible for the payment. So it allows the billing company to bill the patient rather than write off that claim.

Probably the two biggest examples are:

  1. Screening mammograms for any patient who is of Medicare age
  2. Pregnancy ultrasounds (for reasons other than medical necessity).

Cheri: ABNs are a good thing, but hard to get, because you have to present it properly to the patient. If a patient goes in for a service such as a mammogram, you’re going to have the hospital billing part of it and you’re going to have the radiologist billing part of it. The patient has to be told what the fee is for both the hospital and the radiologist.

So the ABN form is almost a contract – it has to be worded so the patient knows they’re going to be billed by two separate entities and what dollar amount they can expect to be billed for.

But it can be very important for procedures you could foresee that you’re not going to get payment on.

QUICK TIP: If an ABN is not signed, it’s a straight write-off.


The Appeals Process

Lauren: If there is a denial, you have every right to appeal a claim. It’s not always an easy process, but insurance companies are trying to be more proactive. And insurance companies take appeals very seriously.

When I worked at a certain insurance company, they made multiple copies of the hard copy appeal. One went to the manager of the claims department and one went to the big guy who ran the show. He would “green folder” it and send it to the claims department with a timeliness factor built in, saying, “You have to address this appeal within the next seven working days. And if it is not taken care of someone is going to phone you and ask why.”

Patients can also make waves. People are more proactive about their healthcare because of cost and the fact that they’re responsible for such a huge deductible. If a patient takes the time to write a letter to an insurance company executive, then the insurance company may sit up and take notice.
Then the impetus then falls upon the claim processor or the appeals person to make sure that they reexamine the claim and find out, “Did I deny this in error or is there actually something that happened in the system that made it happen?”

QUICK TIP: If other avenues fail, a letter from a patient may catch the attention of an insurance executive.


Written or Phone Appeal?

Lauren: Every insurance company has a different way of handling appeals.

Cheri: You have to know which payors you can call in a timely fashion and get the proper advice. Insurance companies have reduced their customer service staff so dramatically that the wait time on a phone call can be 45 minutes.

Lauren: In many cases, you can now file appeals through an insurance company’s website or send a message to a claims rep – they’ll often respond within 48 hours.

If it’s not an easy fix, like a group number being wrong, then a written appeal may be needed. In these cases, an insurance company will often supply a special form.

Karen: Does a written appeal require certain skills?

Cheri: Yes. An appeal can be very tricky to write, because each payor requires certain things. You have to know the guidelines for each company, you have to have the right forms, and the verbiage is very important. They need to understand exactly what you want them to do. It is not effective to work a denial twice, so you have to get it right the first time.

For example – this seems silly – but with Medicare, they specifically want you to sign the appeal form “Cheri B.” If I sign it, “C. Brinkman,” it is denied because my appeal form is not filled out properly. On the other hand, a Medicaid program for West Virginia requires me to sign it “C. Brinkman.” If I sign it, “Cheri B.,” it’s denied. You have to be very specific with the state and what kind of product you’re dealing with.

Lauren: It truly is a judgment call. The mom-and-pop insurance companies – the ones with the green folders – may be the easiest to convince over the phone.

Cheri: Yes. They’re very concerned about their denial rate and getting it paid, and they’ve got long-time employees who know what you’re talking about. With the bigger companies, it’s not as quick, but much more effective to do a written appeal.

QUICK TIP: With bigger companies, it may be more effective to do a written appeal. Then you’ve got the paper trail of what’s been discussed.


Insurance Processing Errors

Karen: This is a very, very big problem with electronic claims. Radiologists and billing departments are at the mercy of how insurance companies are managed front-line. If there’s a training issue in a large center and someone is manually doing something that’s causing a rash of denials, we’ve got to figure that out. If a payor’s front-line staff is in turmoil, then you’re more likely to see denials.

Lauren: I agree. It can be extremely frustrating when you’ve got a load of explanation of benefits in your hand with a code stating that all of the claims have the same problem – maybe they’re all patients from the same group – and it was a group number issue.

Cheri: And we tend to get denials by bunches, so if we get one denial for a specific insurance company, we’re going to get 20. But most insurance companies won’t take what we consider a “mass appeal.”

Lauren: I don’t think insurance companies absolutely want to deny claims; they often happen automatically, especially from the electronic end. They may be triggered by internal claim audits. Many things, just through communication, can be resolved.

It’s in your best interest to talk to your account executive at the insurance company and state your problems and say, “Listen, we’re doing everything right to make these claims go through, but for some reason they’re being denied. And if it’s our fault then you need to tell us what we’re not doing properly at our end.” But I have to say all call center employees are on a call queue, and it’s sort of the luck of the draw.

Cheri: They’re always very, very polite and helpful, but if the person you get on the phone is only looking at the claim that’s in front of them, they don’t necessarily know the scope of the problem. And by the time you get through the chain of command at an insurance company, you’ve spent a lot of time and maybe still haven’t gotten it resolved That’s where I go back to saying a written denial or a written appeal to a large company is sometimes more effective.

QUICK TIP: Close to 20% of denials may be insurance company processing errors.


Cheri: Medicare is the supposed leader in the insurance companies. So it’s extremely important for a radiologist to subscribe to Medicare’s guidelines and daily bulletins. If you know what Medicare is proposing and/or doing within the industry, you can assume the rest of the players are going to be doing the same.

Lauren: Medicare’s biggest denial is typically diagnosis-related. They have very specific guidelines to follow, and if you don’t code it as such they will not pay it. Typically those are very easy to resolve – you just resubmit the claim with the correct information; you don’t even have to appeal for the most part. But they are very, very specific, so it’s important to know what Medicare has in the pipeline and how it will change the scope of our jobs.