Don’t make the mistake of working too hard for too little.

By Kathy Mills Chang, MCS-P

Practices often spend valuable time and energy tracking down and re-filing claims that should have been processed correctly and efficiently the first time.

The amount of time and money your practice probably spends attempting to collect accurate payments from insurance carriers is not only staggering, but the costs associated with the process are high.

For example: secondary claims. Your CA staples the primary explanation of benefits (EOB) to the secondary claim and uses a red marker in Box 19 on Form CMS 1500 to write “EOB attached.”

Four weeks later, you receive a letter from the carrier stating they can’t process your claim without the primary EOB. You then call the secondary carrier and explain that the primary EOB was attached.

You wait on hold for 15 minutes while they go and search for it. When they return to the phone, they say that they have found the EOB and it will be sent back for reprocessing.

It will take approximately three to four weeks before you get the 20 percent owed on a $28 visit. That’s $5.60 minus what it cost you to collect it. If there happened to be six visits on that particular claim form, that’s $33.60 in revenue just sitting out there.

Insurance carriers haven’t singled you out for torment by making you wait for claims payments, and it’s not a conspiracy against chiropractic.

Difficulty with claims processing is a problem that every provider of every specialty has to deal with. It has been estimated that claims processing errors by insurance carriers costs the healthcare industry an estimated $17 billion per year. The average error rates for claims processing is estimated at 20 percent.

Therefore, 20 out of every 100 claims may be processed incorrectly, often through no fault of your own. Regardless of how squeaky clean your claims are, it’s inevitable that some will be denied no matter what.

The convoluted and confusing world of insurance rules and regulations will not only make your head spin, it’s invariably going to cause some of your claims to be denied as well.

There needs to be better transparency, more consistency, and improved efficiency across carriers and between providers and the carriers. Until that happens, you will have to find ways to minimize the administrative financial burdens associated with inefficient claims processing.

So what can be done to mitigate these circumstances? The following strategies will give you a leg (or several percentage points) up in the process:

1. Make sure submitted claims are clean and coded accurately. Some practices use claim scrubbing (aka claim

editing) software that ensures the data on the billing form is correct prior to submission.

For example: If the date of service is prior to the date of the first injury/illness (Box 14 on the CMS 1500), the claim is flagged and then denied.

These types of common mistakes can be easily corrected prior to the claim being filed. In addition, most claim scrubbers utilize a “rules engine” to ensure your CPT codes and modifiers are associated correctly with the diagnosis codes to justify the medical necessity of the procedures being billed. Don’t turn that feature off. It is there to help you.

2. Work your aging report faithfully. If you only do follow up based on what comes in the door, with errors, you will never get back to those claims that were never processed.

If you can, print your aging report by payer class from highest- to lowest- balance due. You will be amazed how many times you hear, “We never received this claim.” If you hadn’t worked proactively, the unpaid bill would just sit there, unattended and unpaid.

3. Work reactively as you process paid claims. If a bill is not paid in full, has services left unpaid, or has arrived as a “zero pay,” work these into your reactive call or reactive action system to ensure time is allowed to follow up, oldest to newest.

4. Have a tickler system. Whether paper or electronic, this helps keep track of what is pending and ensures that it’s not overlooked or forgotten.

As you work a reactive or proactive item, place a reminder in the system — whether to remind you to watch for a payment, return a call, or to be expecting something.

5. The components of the system belong to the practice not to Sally, the insurance CA. Make sure the system to be followed is fully installed, trained, and written in detail in your standard office procedures.

That way, when Sally wins the lottery and moves to Cancun, she won’t take all of that knowledge and information with her. It stays with the system that stays with the office.

Even though $33.60 may not seem like it’s worth the trouble or effort to go after, $33.60 times 20 (claims processing errors in one month) equals $672. $672 times 12 months equals $8,064 a year. $8,064 times five years equals $40,320.

That’s a lot of money to just let fall through the cracks. Due diligence and effective claims tracking systems will ensure that the money ends up in your pocket — where it belongs.

Kathy Mills Chang, MCS-P, is the founder of her own consulting firm assisting doctors with finding financial and reimbursement ease in practice. She also serves as Foot Levelers’ insurance adviser and can be reached at 888-659-8777 or info@kmcuniversity.com.