Q. Why is a claim denied for “medical records” even when the patient has been getting the same treatment for years?
A. This could mean that they have hired an outside firm to help cut costs, and because that patient is on an expensive drug, they want to see if the patient still needs the treatment. Unfortunately, there is no simple way around this. You will have to provide the documentation to keep this claim moving. To save time and effort, make sure you meticulously document each case (taking advantage of your electronic medical record [EMR] if you are using one) so you can quickly resolve this by providing the information requested.
Q. When I call and tell the representative I have sent in the requested medical records several times via certified mail, which was received, he tells me they still do not have the records. What could be the cause of this?
A. The insurance company may outsource their calls. If this is happening, it is likely the customer service representative cannot verify if the records were received because he or she isn’t in the office where they were sent. Tell the representative you do not want a general mailing address for medical records but the name and address of the person who should be receiving this type of communication. That way, your mail is going to a specific person—not just to the mail room.
Contacting insurance carriers can be both time consuming and frustrating to your staff. The tips and tricks above are not always guaranteed to work. As anyone who works with insurance carriers—or calls any type of customer service line—knows, each company has a different set of policies. However, rheumatology practices should take the steps to be as well prepared as possible when making calls to carriers.
By doing some research beforehand on the carrier’s Web site, and by knowing your state insurance regulations, your staff can save themselves a lot of time and effort. If you have exhausted your options, the next best step is to contact your state insurance commissioner to file a complaint, and to contact your county and state medical associations for additional support in resolving the matter.
For more information on how to effectively communicate with insurance carriers, contact Melesia Tillman, CCP, CPC, at (404) 633-3777, ext. 820 or by e-mail at [email protected].
