What to do When a Claim Doesn’t Get Paid

Occasionally we get that response on a claim that was filed electronically even when we get the acceptance report from the clearinghouse. It’s not common but it does happen. Even though we received acknowledgment that the claim was received the best thing to do is resubmit. We verify to make sure all info is accurate such as name spelling, ID#, date of birth, and sex of the patient. If the claim is denied for timely filing, we appeal with our initial acknowledgment.

But then there are the paper claims – claims for workers comp injuries or no fault (auto) cases or personal injury accidents and even some obscure insurance carriers. Claims are filed on paper and no acknowledgment is received. You wait for payment or some explanation of what they are doing with the claim, but none comes. You try to call but getting someone on the phone is impossible. They aren’t like the larger insurance carriers with automated systems or better yet online claim look-up tools. At best you get a voice mail but if your experiences are anything like ours the messages go unanswered.

So what are our options? Keep submitting the claims into a black abyss costing more time and postage? Continue leaving messages on voice mail that appear to not be manned? Unfortunately there is no magic trick to handling this problem but we have come up with a system that helps to resolve some of these evasive claims.

We’ve developed a form that we use when we have a claim that we’ve submitted twice, haven’t gotten a response and can’t reach anyone by phone. It’s a very simple form. We use our letterhead with our address, phone and fax numbers. We write a brief note at the top stating that attached is a claim or claims that we have previously submitted at least twice with no response from the insurance carrier. Would they please let us know the status of this claim.

We then write in on lines we have labeled the current date, the provider’s name, the dates of service. We then have three check boxes for the insurance carrier to respond with the appropriate response labeled paid with a place for date paid and check number, denied and reason for denial, and not on file. Next we leave a line for the date we are submitting our request. We then leave three check boxes for the insurance carrier to check the appropriate response. We then request this form be faxed back to 315-865-6359 and the person requesting the information signs the form.

We have been amazed at how well this has been working for us. Some insurance carriers mail them back and some fax back and some ignore them too but we are getting responses to most and they come back quickly.


2 Responses to “What to do When a Claim Doesn’t Get Paid”

  1. Marian Funderburk Says:

    This is good information – for a new person in the business it is easy to give up after a few times, but the key is to re-submit the claims in ways that will require a response from the insurance claim rep. I have a couple of claims that’s one year old. Any special secrets about collecting on them?

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