If you are trying to submit claims for a provider who is out of network with the insurance carrier you will most likely run into some problems. For example, if you need to call on the claim you may find that the insurance carrier will not even speak to you since you are out of network. This makes following up on the claim difficult.
Some wonder why you would want to follow up on a claim that is out of network. Sometimes it is not the provider’s choice to be out of network. Or possibly they are trying to help the patient out. In our case, it was an inpatient drug rehab that just opened, still applying to be in network, but accepted the patient as an insurance patient. They had us submit the claim but they are waiting for the payment.
We submitted the claim and then called 2 weeks later to be advised the claim wasn’t on file. We then faxed them the claim and called again 1 week later. Now we were told the claim was received and was in process. Fortunately we didn’t rest on that information. We called again 1 week later to find that the claim was ‘lost’. Now I couldn’t figure out how it could be lost since we were told it was received and in process, but this new person was now telling me that she was sending it back for processing and ‘telling them where to find the claim”.
The funny thing was that we received a letter that day with the claim being returned stating that the type of bill was not a valid type of bill code. Isn’t it amazing that we were told such different information when we called? Well our type of bill certainly was valid, but it turns out that Blue Cross just requires a different type of bill. Now we’ve resubmitted the claim with the new type of bill and you can bet we will keep calling until payment is made.
There are other problems that you can run into when submitting out of network claims. In some cases patients have no out of network benefits which means no payment will be made on the services. Usually out of network claims are paid directly to the patient and this may not be a problem for you if you are just verifying if the claim was paid. If you are waiting for the payment then it can be helpful to know when the patient is receiving the money.
For those of us who are responsible for submitting out of network claims for providers we just have to be diligent in following up on the claims. It is not an easy task but if you just stay on top of it, it can be done.