How strong is your revenue cycle team? If you’re struggling with getting commercial health insurance companies to pay their claims on time, then you might want to take a good look at your billing department. Chances are, they’re overloaded or undertrained. Bringing in some new employees to supplement them will help with this situation, and will possibly solve your current cash flow problems. Although there’s always the chance that those claims will end up getting sent through the appeals process no matter what you do, with more revenue cycle employees, the odds that they’ll get lost during that process are much smaller. Here’s what you need to know.
Revenue Cycle Management Employees
If you’re like more health care practices, you already have a billing department staffed with knowledgeable employees. The main question is: do you have enough of them? Odds are, you don’t. You need more people with specialized skills who can help you get to the bottom of your unpaid claims issues. It all starts with hiring the right employees. According to one expert, you need to “Determine the skills you need in a new team member. These can include certifications, ASC experience, and surgical coding skills.” This is crucial because you’re hiring people who can fill in the gaps between what your current employees know and what you need them to be able to do.
Next, you need to find those employees. This starts with a solid job description that appeals to potential employees and explains what they must be able to do. Then, you need to “Post the job opening on healthcare job boards, such as those hosted by the Ambulatory Surgery Center Association and professional revenue cycle associations.” These are some great places to locate employees with those particular skills.
The next step involves testing those employees. You need to ensure that they can do what you need them to. Also, if you find an employee that you like, but who needs a little extra training, then you know where to steer them in the right direction. Don’t be afraid to “Create a coding test for applicants to take as part of their interview. This helps to ensure the applicant is qualified for the position.” However, if they don’t know everything, be prepared to train them to fit your needs.
Finally, the last step in this process involves hiring them and getting them ready to work. You need to “Prepare your new hires for success by auditing their work. Share collections data with them and the entire team.” They also need to know how to track appeals.
How the Appeals Process Works on the State Level
Hospitals and clinics tend to go through a lengthy appeals process on the state level, especially if they’re dealing with out of network claims. Here’s how the system works in general: The patients have procedures done or meet with doctors. Some of these are standard checkup appointments, others are outpatient procedures, and still, others necessitate a hospital stay of some kind. The hospital billing employees go through everything that transpired in order to determine the correct billing codes and amounts. If the procedure was out of network, this is even harder to determine. The assigned codes depend solely on the doctors, the procedures, the care involved, and any medications that are prescribed. These coded bills – now called claims – are sent out the commercial insurance companies. The company that they are sent to depends on who that patient’s insurer is. This sounds easy, right?
At their end of things, the commercial insurance company has a process that they go through in order to pay those claims. In some cases, they’ll pay a portion of it or reject it outright. If the claim was out of network, it’s more likely to be completely rejected. The hospital’s billing staff has the ability to appeal these unpaid and rejected claims at the state level. They can do this three times. The problem is that’s a lot of paperwork to have to deal with in a tight time frame, which is exacerbated even more by the fact that the claim is for an out of network procedure.
More About Those State-Level Appeals
In the end, if your clinic or hospital gets lucky, some, or at least a portion of those claims will get paid. If you aren’t lucky, those claims will go and forth for the allotted time frame and end up being completely unpaid. The reasons for this can vary and depend on many different things, including billing codes, pre-approvals (which are hard to come by for out of network procedures), and what the commercial insurance company thinks should be covered or paid for.
After those three state-level appeals are exhausted, your hospital could file Federal ERISA appeals on all of those unpaid or underpaid claims. The problem with this is that your billing staff doesn’t know how to do this, nor do they have the time. The process is complex, and most billing departments are busy either with sending out current bills or wading through state-level appeals. In most cases, those unpaid and underpaid out of network claims end up getting written off.
Taking the Next Steps – Federal ERISA Appeals
The Federal ERISA appeals process is designed to get your clinic and hospital the money that it’s owed from those commercial insurance companies, even for out of network care. The process works in a very simple way. Rather than letting those claims sit around or having your accountant write them off, organize them into a file and then contact a company that specializes in these types of Federal ERISA appeals. ERISA Recovery is one such company. We know what we’re doing and have the knowledgeable staff on hand to deal with the Federal ERISA appeals process. In the beginning, all that we will need from you is a list of those claims and some other information. From there, our trained employees file the appeals and will get you that money. At some point, we might need some additional information, but that all depends on the claims and the Federal ERISA appeals that pertain to them.
The best part? We guarantee that we’ll recover at least one million dollars in denied claims within 12 months, and we don’t charge anything for this service up front. We don’t get paid unless you do – we work on a contingency basis. This gives you a great option to choose. Instead of having those claims end up on the wrong side of your hospital or clinic’s balance sheet, you’ll find it in your bank account. We know how tricky it can be to recover these out of network claims and things have been made even more complicated by the January 2018 decision.
We Have a Good Solution for Those Appealed Claims
Now that you understand the difficulties of billing out of network claims and how useful the Federal ERISA appeals process is, it’s time to make a decision. You can either let those out of the network claims pile up or lead to possible financial ruin, or you can call us. We can get you that money. All that you need to do is call us today at (972) 331-4140. You can also fill out the contact form on our website. It’s time for you to make that choice.
