WCH is committed to the success of our clients. For over 20 years, we have been resolving thousands of claim denials and underpayments directly with various insurance companies and other payers. At the same time, we have helped our clients tackle issues related to their insurance contracts or absence.
Today we would like to share a story that has affected both - a timeline of countless claim denials that have occurred due to a discrepancy with a provider's participation. Awareness and attentiveness to details are critical when it comes to a successful billing flow.
One of our clients is a large multispecialty group that is out of network with one specific insurance. As a result, this group has accepted only patients with out-of-network benefits, subsequently negotiating all the claims submitted with a third-party negotiator. However, one provider had been experiencing issues with the way the claims had been processed. Namely, none of the claims had been accepted for adjudication. Hundreds of claims had been rejected because the payer did not have the license information of that provider in their system. As a result, we had to submit the provider's credentials to the payer for nearly every claim to make it paid. This issue had been ongoing for over a year, up until the moment when we finally decided to contact the credentialing department of the insurance to find out what was going on with this provider's record.
The payer has advised us to submit the mentioned license information to their credentialing department once and for all. We did that, emphasizing that the provider would still wish to be out of network with the plan. Upon receiving a confirmation from the payer, the requests had stopped, and the claims had started to be paid instantly. Mission accomplished, isn't it?
No, it is not. Shortly after the payer had updated the provider record, we have identified that our client had been paid less than they were supposed to be. The difference was drastic, with some claims being underpaid for over 50% compared to the amount paid before a record update. We had to look through each claim only to find out that the payer had been applying contractual obligations to payments issued to the provider!
Numerous calls to customer service have not brought any result. We were simply told that the claims had been processed correctly and out-of-network, which was not true! Contractual obligations cannot be applied to out-of-network services simply because there is no contract.
We have resolved this issue after a lot of phone calls, appeals, and the involvement of a payer's network manager. Apparently, due to a glitch in the payer's system, the provider mentioned above had been showing up as "participating."
Such cases teach us that it is critical to carefully check your Explanations of Payment and keep your credentialing in a good order to be adequately paid.
