Effective collections follow up results in the speedy resolution of your medical office claims. Claims follow up should begin as quickly as 7 to 10 days after your claim has been submitted for payment. Immediate efforts to get claims paid will not only reduce your accounts receivable days but also increase cash flow.
Adequate staffing with proper collections training will provide the desired outcome in your the collections phase of the revenue cycle. Medical office staff should be aware of the fundamental steps necessary for efficient follow up of insurance claims.
1. Initial Contact
Be well prepared. Once you finally get an insurance representative on the phone, you want to have all the information that you will possibly need at your disposal. Research the account thoroughly to ask the proper questions. Have the facility Tax ID and NPI in addition to the insured's name, date of birth, policy number, date of service, etc.
Be sure to get the insurance representatives information. The name, extension number (some companies use an employee id number), and before hanging up, be sure to get a call reference number.
Try to get this information early in the conversation just in case you are "accidentally" disconnected. This will allow you to provide feedback to the insurer when you call back and for your own documentation.
2. Ask Lots of Questions
Your goal is to find out when you should expect to receive payment. If it has been more than 30 days from the billing date and you have still not received a response, the insurance representative needs to explain the reason for the delay in payment. Make sure you ask enough questions of the right questions.
- What is the status of the claim?
- When is the claim scheduled for payment?
- Where in the payment process is the claim?
- What is the amount of the payment?
- What is the check number?
- Why is the claim taking so long to process?
- Why is the claim pending or under review?
- Where do I need to send medical records?
- Who can I speak with to get this claim paid faster?
- Why is the claim not being paid according to contract?
3. Be Assertive
Don't be afraid to challenge the insurance representatives. Most insurance companies use stall tactics to delay payment. If you are discussing a claim with an insurance representative, don't let them get away with giving you bogus information. If they refuse to give you a valid reason as to why your claim is being held up, ask to speak with someone of authority, like a supervisor.
While you have the insurance representative discussing the claim, find out if there may be any other missing or invalid items that could hold up the claim from immediate payment. If you develop good rapport with at least one insurance representative for each carrier, you may be able to convince them to give you more details about the claim than usual.
4. Take Appropriate Action
Now that you have found out the status of your claim you can take approriate action to speed up the payment process. Whatever action you take depends on which one of the common stall tactics the insurance company has used to delay payment.
Manager/Supervisors: Make sure there is a policy in place so your employees will know how to quickly resolve any one of the following:
- No claim on file
- Medical records needed for further review
- Need primary insurance COB information
- Information needed from the member/subscriber
- Prior authorization not on file
- Referral not on file
- Information on claim missing or invalid
- Need pre-existing information from primary care physician
- No medical necessity
- Accident details required
5. Involve the Patient
This should be a last resort but it may be a necessary one.
There are a few ways to handle this step.
- Send the patient a bill. Patients usually respond especially if they expect to pay little or nothing for their visit. They will either call you or the insurance company. Either one is good.
- Contact the patient by phone. Use this call to get the patient's help in getting the claim paid. Get the patient on your side. They don't want to be responsible for the bill, that's what they pay insurance premiums for.
- Initiate a conference call. If you can get the patient on the phone, try to arrange a conference call so that you can be witness to whatever is discussed between the patient and the insurer.