Many people do not realize the frustration a medical biller encounters when filing insurance claims. It represents one of the major reasons some billers write off finances owed to their employer.

 

Obviously, when a claim is filed, there is a possibility it will be denied. When appealing a denied claim, a phone call to the insurance provider might lead to some interesting conversations.

 

"That person on the other end of that call might not be as bright as you may think," said Minerva DeJesus, co-founder of Simple Solution Billing in Maitland. "For example, we got denied on a claim for a urinary tract infection because the insurance provider stated a urinary tract infection is a pre-existing condition. That's like saying a common cold or the flu is a pre-existing condition!"

 

Another example: a claim was denied for a pap-smear because the insurance provider believed the name on the claim belonged to a male instead of a female.

 

"Why would they come to that conclusion when they should have the patient's information in their system? Remember, this patient did have to apply to get coverage," said Auriana "Audi" Reyes, co-founder of Simple Solution Billing and owner of a thriving local ultrasound company. "We've even come across an insurance provider requesting medical records to pay coverage on a well woman's check-up, which is something a female must get done every year per doctor's orders. A request for medical records is done to verify the medical necessity for the patient's visit. The claim is self-explanatory. It is a routine well woman's visit. Any woman can assure you, we don't like getting this exam performed. We are only doing it because it's medically necessary."

 

Insurance claim adjustors sometimes cannot interpret their own explanation of benefits, joked DeJesus.

 

"A negative symbol in front of an amount on an explanation of benefits document doesn't mean the insurance company covered the charge," she said. "A negative balance usually represents what the insurance company wants the patient to cover. When we called to inform the insurance company that they owed this amount, they insisted they already paid it. It wasn't until we explained their own paperwork to them that they realized the claim was denied in error. Why do we have to explain their own paperwork to them?"

 

Even when mistakes have been identified and denied claims have been resubmitted, the insurance company might deny them a second time because of "untimely filing," meaning the claim wasn't submitted before the insurance company's due date.

 

"This particular trick can be handled by proving the original claim was submitted during the correct time but was denied due to ignorance on the insurance company's end," explained Reyes. "Sometimes, an insurance company will deny a claim for no reason. They don't need a reason if the biller doesn't follow up on it before the filing deadline."

 

Insurance companies don't always meet their own deadlines, such as when a patient has a pre-existing condition clause on their insurance plan.

 

"The insurance company will put a hold on paying a claim while they obtain medical records from other physicians who have provided care to the patient," she said. "In these scenarios, the claim is held by the insurance company pending medical review. The insurance company is not eagerly pursuing these necessary documents as they are not in any rush to pay for the service provided by the physician to the patient in need. They only send out a few requests and not to every physician involved, leaving it in an undecided status for just the right amount of time to get denied, using the reason that they were unable to obtain the right records needed for approval. This puts the liability back on the patient when it clearly is not their fault or the fault of the physician who rendered services."

 

DeJesus emphasized that insurance companies take necessary measures to deny, or at least delay, payment of the claim.

 

"We need to ask if the biller submitting the claim is smarter than the insurance company they are submitting the claim to," she said. "The insurance company is hoping that they get away with this nonsense. They pray no one is paying attention because while you aren't given a second thought … the pennies are adding up, taking away from the physician that has worked so hard providing care to the public and not having the finances to show for it. Remember not reading between the lines will affect your bottom line and result in lost revenue. Learning to outsmart the insurance company at their own game is the only way to keep those numbers up. It's only fair to get paid for the service these physicians provide to their patients and their community."