Jump to content

Claims problems


Guest kchristy
 Share

Recommended Posts

Guest kchristy

Karen:

Without much detail about the nature of your claims problems, I'll have to address the general areas in which I've seen difficulties in the past.

First, every claim system has a table that compares the "procedure code" of the medical service performed against the "diagnosis code" that the doctor or facility provides as part of the claim. If the system does not recognize a procedure as being a valid one given the diagnosis (for instance, a tonsilectomy on a patient with heart disease), the claim will be denied.

Second, we see problems arise due to "unbundling." Modern provider contracts often feature "case rates," which provide a fixed fee for the treatment of a particular diagnosis, and rate structures that incorporate a number of different procedures under one payment code. For example, a carrier may, under a procedure code for tonsilectomy, write in the contract that the payment for the tonsilectomy includes all charges for anethesia. If the provider then bills separately for the anethesia (or "unbundles" it), that service is denied.

Finally, there is a problem peculiar to point of service plans, particularly capitated ones. We have found that if a patient self-refers to a physician who is a member of the same medical group that the patient is enrolled with, the claim is returned to the medical group by the carrier. The reason for this is that, in the carrier's reasoning, the member may have been referred by his or her primary care provider to that specialist, in which case the specialist should be paid by the medical group, and not the carrier. If I had a dollar for every time this happened, I could probably retire. What is required is that the specialist make sure that the claim form is clearly marked that there was no HMO referral involved, then *maybe* it will go through without a hitch. Maybe.

Hope this helps. -Kevin

Link to comment
Share on other sites

Guest Karen Renee

We are a manufacturing company with a self-funded POS plan with Blue Cross Blue Shield. We continually have claims problems where the physician or hospital has billed a claim in such a way that it is denied, when it some instances if it had been billed differently it would have gone through. Anyone else experience these problems? What things can be done by the insurance carrier? How has it been handled with the employees? Any thoughts?

Link to comment
Share on other sites

Guest Lori Senter

One thing I've also seen, especially when managed care is new to a group of employees, is that the doctors may not be used to preventative care being covered. We had a plan where preventative care was not covered at first, then added later. The doctors were so used to putting diagnosis codes on the claims so that truly routine visits could be paid, that when we added the coverage for routine visits, the claims were being applied to the employees' deductibles instead of paid. Of course, all that is fixable, but what a pain in the neck. A little employee education seemed to help a lot in our case.

Link to comment
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
 Share

×
×
  • Create New...