Q. Why is a claim denied because it is not “medically necessary”?
A. This likely means that your diagnosis code does not match that particular service. The carrier will not tell you the correct diagnosis code to use, so you must look at the medical policy—which can usually be located on the carrier’s Web site—to find that information yourself.
Q. Why do customer service representatives tell me they can only take a certain number of inquiries per phone call?
A. As frustrating as this is, it boils down to quality assurance. When a customer service representative limits your number of inquiries, it is usually because his or her quality of service is based on the wait time to answer calls—in other words, the ability to turn over a high call volume. If a representative is on a call with one person for too long, it increases the wait time for other callers; therefore, the representative’s quality would be at an unacceptable level. There is no way around this one—particularly with CMS—as this is usually policy. Your best option is to make sure you prioritize your cases and questions before you get on the call and have all information for each case in front of you. This will give you the opportunity to make sure all of your questions are addressed and will allow the representative to maintain the quality level the carrier has deemed appropriate.
Q. I have placed multiple calls to get a claim corrected. Each time, the representative tells me it will be corrected, but there has been no progress. Why are representatives telling me one thing and not following through?
A. This is about getting you off of the phone (i.e., quality level), or the representative does not understand medical claims processing. Often the customer service representatives you speak to have just enough training to answer the phone and take a message but not enough to truly understand and answer your questions. To prevent this pattern from continuing, always document the date and time of each call along with the name of the representative who helped you. Once you have documented a few calls with failed results, you can take this documentation to a supervisor of that carrier by calling the customer service number and immediately asking that the call be “escalated to the supervisor.”
Rheumatologists’ recommendations for choosing an electronic medical record
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