How to Handle Problem Claims

One of the things that differentiates a good biller from an average biller is their ability to get to the bottom of a problem claim. To some of you, this may seem like a no brainer. That’s a good sign. You assume it’s a given to be able to get to the bottom of a problem claim. But unfortunately it’s not always a given.

Some billers do not take the time to get to the bottom of the problem claims; they just mark them as uncollectable or bill the patient. Some do this because they don’t want to be bothered or take the time necessary to deal with the issue; others do it because they simply do not know how to get to the bottom of it.

These problem claims can add up and if not handled could cost a provider a lot of money at the end of the year. Many times the provider isn’t aware that these claims exist let alone know if their biller is handling them or not, but they should.

Problem claims do not have to be such a headache. They just need to be dissected and the necessary action needs to be identified. First, start by deciding if the claim was handled properly by the insurance carrier. If you do not believe the claim was processed correctly you should start with a phone call to the insurance carrier. Sometimes these things can be cleared up with a simple phone call. Even if the issue cannot be resolved with the phone call, the customer service representative should be able to tell you what action needs to be taken.

If you have a claim that you are unsure of why the claim was processed the way it was, call the insurance carrier and ask them to explain it to you. They should be willing to go thru the claim and explain why they did what they did. If you do not agree with the explanation you can appeal the claim. Just make sure you attach any documentation that you have to support your position. The more documentation you supply the better your chances are. Remember sometimes things are processed a certain way because of the plan provisions and no matter how much documentation you attach the decision will be upheld.

A claim may seem like it is a huge problem but in reality it is usually just that you need to identify the problem and determine what action you need to take. Don’t let a problem claim intimidate you into just writing it off. Make sure you determine if it is truly a service that you cannot be reimbursed for, if the insurance carrier made a mistake, or if the patient is responsible and then handle it accordingly.

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One Response to “How to Handle Problem Claims”

  1. phyllis brill Says:

    Do you contact the appeals and grievances department?


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