Getting Claims Paid on Time

Q: I billed an insurance company about three months ago and still have not received payment. What should I do to get this claim paid?

A: An insurance carrier is required to pay claims in a timely matter provided the information submitted is sufficient to adjudicate the claim. This is an insurer's fancy way of saying that if the claim we send has errors or is incomplete, the insurer is not obligated to pay. The standard time frame to pay a provider on a clean claim varies from as few as 15 days to as many as 45 days, depending on the individual state rules. Considering your claim was sent three months ago, it certainly would appear it is late.

While many providers assume the best option is to immediately jump on the phone and call, this practice is time consuming and not efficient. If you have ever called an insurance carrier to inquire on a claim or simply verify insurance, you can attest to the time it can take. Typically, a phone inquiry will take you through a series of phone prompts; once you have finally dialed the proper extension, the hold time is routinely from 10 minutes to a half hour. Imagine having to call on even a few unpaid claims in addition to the other office tasks: billing that needs to be processed, a waiting room of patients, incoming phone calls, etc. Just doing a few claims in this manner could take up your entire morning or afternoon, with no other tasks accomplished.

Therefore, I recommend you begin a procedure in your office that will offer the most efficient use of time and also create a paper trail for verification should the actions that were taken be disputed later. Any claim aged beyond the timely payment window should go through the following process.

1. Verify that the claim was sent (and sent to the correct address) by verifying the address on the insurance card with the address on the claim form.
2. Do a quick audit of the claim form for correct format and coding. Note that claims that have improper diagnosis or procedure codes are incomplete and the insurer need not pay in a timely fashion (or at all).
3. If the above two steps were done properly, send a "tracer" (a copy of the original dated claim) to the insurer. On the outside of the envelope being sent with the tracer, write "Claim Inquiry." This type of claim must be handled separately from regular claims and will get special attention from the insurer. A note or sticker on the claim indicating that it was previously submitted is helpful as well.
4. If there was incorrect information or an improper address, make the necessary corrections and submit the corrected claim.
5. Log the date the tracer was sent in the patient file.
6. A copy should be sent to the patient so he or she is aware insurance is not paying. It also would be worthwhile to include a short note to the patient that the claim is unpaid, and that if not paid, the patient is responsible. This should prompt a phone call from the patient to you or the insurer on why the claim is unpaid. The patient should be encouraged to inquire directly about the nonpayment to his or her insurance.

This simple procedure will allow the processing of several tracers in a short time and will free up valuable time to spend on all of the office duties that need attention. An office should not come to a standstill for follow-up on a single claim. And, bear in mind that a tracer also must be responded to in a timely manner and by another section of the insurer. Many times, this correction will get the claim paid very quickly, as all insurers are required under the law to respond and you will now have two separate documents pending and requiring response.

Furthermore, by putting the patient on notice that he or she may be held fully responsible for the bill, the patient typically will take a proactive response and make the call to the insurer to limit his or her own liability, if nothing else. As a matter of policy, all of your patients should sign a financial agreement which indicates that insurance is a patient contract, and that while you will bill the patient's insurance as a courtesy, payment of the claim is ultimately his or her responsibility.

If there is enough free time, making an inquiry via the phone is an option. Once connected to a live person who verifies the claim was not received, inquire if the claim can be submitted via fax; most insurers will accept a claim in this fashion. Claim status also can be monitored online (via the Internet) courtesy of HIPAA, but only if the provider or office has set up electronic insurance verification of coverage with the carrier.

The most effective tool to ensure timely payment from an insurance carrier is to send a clean and correct claim initially. For delays in payment, a follow-up procedure that is consistent and timely is best done via the mail, with the patient being the most effective on phone inquiries (as the insurer has a direct responsibility to the patient as the insured).

Also note that some insurers will request additional information from your patient, particularly when a diagnosis indicates trauma or injury, as the carrier will want to see if the patient has another party that is liable. This is common when diagnoses fall in the 800 series. Therefore, be sure your patients are aware that should they receive a request for information from the insurance company, they should respond in a timely manner and should call your office for assistance in filling out any forms or responding to the inquiry.

Finally, a complaint to the state Department of Insurance from the patient and the provider, where allowed (not all states allow complaints from the provider), also is effective, as the carrier knows its governing agency may potentially be auditing the carrier's practices. No one likes to have someone looking over their shoulder; therefore, as is typically, it is the squeaky wheel that gets the grease.