As you may have noticed, certain payers deny payment for claims in error, and they are often reluctant to admit their error. Reprocessing such claims to get the promised payment may turn into a nightmare of endless calls and appeals.
Let us take a look at how we have helped one of our clients to swiftly reprocess the incorrectly denied claims.
A large batch of claims with TMS treatment was submitted in a timely manner to the payer, and the total expected payment was about $19 000.
Case 1
For this one, all billed claims with subsequent sessions of TMS treatment got denied. The insurance carrier did not show that the initial session CPT 90867 was billed, but this claim was on file and already paid.
All efforts to send claims to the payer's customer services representative were futile, and both levels of appeal yielded nothing. The claims were sent back for reprocessing and got stuck in the system. For more than 2 months, there was no payment.
The doctor was frustrated for not getting paid for the 76 sessions rendered to patients. But we did not give up. Instead, we addressed our complaint to the New York State Department of Financial Services where we proved that all services were billed correctly and there was no reason for the delay in payment. After the DFS review, all claims were paid with interest!
Case 2
In the 2nd case, the claims were incorrectly denied for the absence of authorization. However, the provider's office checked the patient's eligibility with the plan three good times, and it was advised that there is no authorization required for the member.
The claims were sent back for review several times, and both levels of appeal yielded no result. The patient's plan still showed that authorization was required, but we had all documentation that proved otherwise. The payer left the claims pending for 2 months, so we sent a complaint to the DFS of NY as we did in the first case. Again, upon the review performed by the DFS, the claims have been reprocessed and paid in full!
With these results, we have demonstrated again how experienced we are at what we do; we do more than just claims billing. WCH works closely with insurance companies while being ready to appeal denials and reprocess rejections, no-pays, and delayed payments so as to ensure that our clients are in good financial health.
