An effective insurance model helps healthcare organizations in recovering over-due payments from insurance carriers easily and on time. This is when accounts receivable (A/R) follow-ups come into the picture. It helps the healthcare service providers run their practice smoothly and successfully, while ensuring the owed amount is refunded back in as short a time as possible.
The accounts receivable follow-up team in a healthcare organization is responsible for looking after denied claims and reopening them to receive maximum reimbursement from the insurance companies.
We have been providing healthcare back-office support services for the last 17 years. We have a team of brilliant medical insurance support executives who can help you with re-submission and repair of denying claims. We have compiled a list of issues & actions in common AR & Denial Management scenarios.
Top 12 AR & Denial Management Scenarios
Scenario 1 - When Claims are not on File
Key Points to Analyze
- Mail address of claim
- Fax number
- Doctor referral letter
- Whom to fax the claim?
- Enrolled eligibility status
- Member not on the list
- Date limit Filing period
- Verify ID and Group number
Questions to be Asked
- May I have the claims mailing address?
- Could you please give me the fax number, and should I go ahead and fax the claim?
- Should I check the eligibility status of the patient to verify the entitlement on the DOS
- May I check with the payer to check the availability of the member?
- Should I know the filing limit for this claim?
Scenario 2 - When Claim is in Process
Key Points to Analyze
- Claim received date
- Claim Processing time
- Technical Protocols to file a claim
Questions to be Asked
- Can I have the receiving date of the claim?
- What is the general timeline to process a claim?
- What are the technical protocols and standards to file a claim?
Scenario 3 - When the Claim is Forwarded to Payer from the Billing Center
Key Points to Analyze
- Claim forwarded date
- Acknowledgment Receipt
- Payer's contact number
Questions to be Asked
- Can I know the date on which the payer received the claim?
- Could you tell me the payer's contact information?
- Could you tell me the payer's contact information?
Scenario 4 - When the Claim is Paid to the wrong address
Key Points to Analyze
• Check Claim Number
• Paid amount
• Permissible amount
• Check date
• Patient's accountability
• Check Write off
• Cashed date
• Pay to address
Questions to be Asked
• Can you tell me the check's number & date?
• What is the allotted amount of the claim?
• What is the amount paid for this DOS?
• Can you tell me if there is any write-off on this claim?
• How is the patient accountable for the claim?
• Will you verify the pay to address?
• Could you tell if the check was cashed?
Scenario 5 - Claim is Paid to the Wrong Address
Key Points to Analyze
• Doctor's correct pay-to-address
• Electronic Fund Transfer
• W9 form
• Appeal via telephone to update
• Canceled check copy if already cashed
• If not, appeal to halt the payment and rerelease the check.
Questions to be Asked
• Can you verify the doctor's pay to address?
• Was the claim filed electronically through EFT?
• Can you update the records if the correct pay-to-address is provided?
• Could you please give me the fax number to fax the correct pay-to-address?
• Can I fax the updated W9 form?
• Could you fax the copy of the canceled check if the check has been cashed?
• Could you halt the payment for the check and re-release the check to the right address?
Scenario 6 - Claim denied for Untimely Claim Filing
Key Points to Analyze
• Filing Limit
• Date of claim denial
• Re-filing & appealing contact information
• Appeal on Proof of timely filing
• Fax number
Questions to be Asked
• Could you tell me the claim denial date?
• Can I know the filing limit for the submitted claim?
• Could you tell me the contact address to appeal the claim?
• Could you provide me with the fax number?
• Can I fax the appeal to your attention?
Scenario 7 - Claim Denied for Non-covered Services
Key Points to Analyze
• Date of claim denial
• Exclusion policies
• Claim summary
• Billing information for the non-covered services
• Verify if the patient can be billed
• EOB appeal
Questions to be Asked
• Could you tell me the denial date of the submitted claim?
• Can you check if the patient is enrolled in the program for billing services?
• Could you state the services which are not covered under the current insurance plan?
• Can I bill the patient for the current claim?
• Would you provide me with a copy of this faxed or mailed EOB to me?
Scenario 8 - Claim denied for EOB from the Primary Insurance
Key Points to Analyze
• Date of claim denial
• Eligibility at the time of service
• Benefits of EOB
• EOB request
• Fax Number
• Maximum frequency for routine service
• Info on primary insurance and coverage benefits
Questions to be Asked
• Could you provide me with the date on which the claim was denied?
• Can you send me the EOB?
• Can I appeal the denial with a request for reconsideration?
• Can you re-process the claim if I fax or mail you the primary EOB?
