Those Pesky Unpaid Insurance Claims!
Doctor, do you know how to run the Outstanding Insurance Claims Report in your practice management software? If you don’t, you should - or at least one of your front office team members should be able to run this report for you quarterly.
There are many very useful reports that can be generated from your PM software, including Production by ADA Code Reports, Accounts Receivables Reports, Adjustments Reports, as well as the Outstanding Insurance Claims Report. You may be asking yourself, “Why do I need to look at this report?” Primarily, because you are the business owner of your practice and you should have an understanding of where all your revenue streams are to know if they are paying off for you.
Two Revenue Streams
The Insurance Revenue Stream
Second, when the time comes for the patient to be dismissed to your Schedule Coordinator, a “guesstimate” must be made regarding the patient’s portion that won’t be covered by the insurance plan. In some cases the insurance plan may cover 100%, but in many cases it does not.
Third, the claim for this patient is electronically submitted to the clearinghouse you are working with. The clearinghouse reviews the claims electronically for any obvious errors such as a missing date of birth. Should an error be detected, the claim is rejected on the report and the error must be corrected so the claim can be resubmitted.
Fourth, you wait for your money! If all goes well and there are no requests for additional information such as a narrative, x-rays or other documentation, you will receive payment for the amount the insurance plan is responsible for within 2-4 weeks. If you are not so lucky, it can be months - despite the requirement that insurance companies must respond within 30 days or pay interest on the unpaid claim unless they have requested information or they are a third party administrator or a non-profit organization.
Fifth is the follow up, and this is where the work comes in. An effective Financial or Insurance Coordinator stays on top of these unpaid claims to improve your revenue stream. This is very tedious and time-consuming, but necessary if you are accepting the assignment of benefits from insurance carriers. The coordinator generates the outstanding claims report for all claims 15 days and over and starts “dialing for dollars”. This call is not really because the payment is expected now, but more to confirm that the claim was received and is being processed. If there is a problem with the claim that the clearinghouse did not catch, you want to know as soon as possible so the claim can be resubmitted. It may take the insurance company several more weeks to “reject” the claim and send you a request for additional or corrected information, or worst case, simply deny the claim.
The goal is that all claims should be paid by the 60-day mark from the time the claim was submitted. If you have claims that are over 60 days, there is a breakdown in your current system. Ask for a copy of the Outstanding Insurance Claims Report and see if your system is working for you!
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