Are Payor Non-payment Issues Affecting your Practice?

It is our responsibility as a third-party, medical billing company to monitor all insurance payment trends and activity to ensure that our clients are receiving the highest and most accurate reimbursement possible.  Often we see insurance payors from all over the nation across all of our clients using incorrect denial codes or applying improper fee schedules.  As a medical billing company, we must be vigilant in identifying issues of integrity with insurance payors.  Some of the most common issues we see involve:

  • Global denials/issues.  These types of denials are marked by multiple non-payments, low-payments, or incorrectly applied denial codes.  Your billing company should be prepared to monitor denial reasoning codes, know what they mean, and recognize when an error has occurred.  Global denials/issues tend to happen across almost all patient claims from a particular insurance company and are fairly easy to identify.  If these types of denials occur, then your medical billing company should immediately contact the insurance payor, preferably the appointed provider representative, and work to correct the error right away.
  • Improperly applied denials.  Insurance payors are incredibly notorious for issuing unfounded claims denials (e.g. no authorization when one was not needed, CPT bundling).  Your billing team must be aware when a denial code is incorrectly applied and how to fix these denials at the onset.  It is possible that insurance payors experience system glitches, which could lead to these types of denials, or it could be a way for insurance payors to avoid making appropriate payment on a claim line.  As a medical billing company, it is almost impossible for us to truly know the reasoning behind improperly applied denials.  Regardless, we must identify when errors like this occur and rectify the issues in a timely fashion as not to disrupt the revenue stream.
  • Fee schedule errors.  I am continually astonished to find that legally-binding contracts are breached on a regular basis on the part of the insurance payor.  More and more we are seeing fee schedules improperly applied, thus leading to lower than required reimbursement.  Your medical billing company should absolutely be monitoring each insurance payor’s fee schedules per your agreed upon contract.  While these are not difficult to apply by hand with the appropriate tools and technology, most practice management (PM) systems have the capability of applying fee schedules at the time of payment posting, allowing for quick identification of incorrect payment.  Our PM system, Healthpac, is readily equipped with this feature and we continuously monitor fee schedule errors and have been very successful in correcting issues with the insurance payor almost as soon as errors are identified.
  • Payor specific “rules.”  As remarkable as it may seem, not all insurance companies are bound by law to follow a specific set of guidelines for billing and reimbursement.  While more and more companies are adopting CMS-guidelines, some actually have payor-specific guidelines, which really are not easily identifiable until a denial or reduction in payment occurs.  Your medical billing team should have the knowledge of how to access payor specific “guidelines” and should contact the payor with further questions should these types of denials and issues arise.

As a medical billing company, we continuously identify payor issues when we are posting payments.  MedPro Services staff are highly skilled in quick claims follow-up and correcting any payor non-payment issues almost immediately upon receiving them.  At some point in time, we have run into each of the above mentioned non-payment issues and have found the best means for addressing each of these issues, so that our providers experience minimal delay in receiving the correct reimbursement.  Are you questioning your medical billing team’s skill in rectifying and monitoring non-payment issues?  Please feel free to contact us for more information on how we can improve your practice’s revenue stream.

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