Timely and accurate insurance filing is essential for quick payment and the profitability of your practice. As a medical professional, you know this and no doubt have systems in place for these issues. However, these are not the only reasons medical claims are denied by insurance. What happens when you’ve done everything right, but your claims are still denied? Have a professional medical billing team at your disposal can make all the difference.

This is exactly the situation for our client in this month’s client study. In this story our client submitted their claim timely and correctly, but the claim kept coming back denied on the grounds the physician provider was not a registered Medicare provider.

Getting to the bottom of this issue was more complicated and time consuming than what the client was willing to do through their own billing department.

ORI Gets Involved As a large, professional medical billing company Outsource Receivables Inc. encounters odd issues in the medial billing world daily. Our experienced staff understands the system and has the wear-with-all to get to the bottom of most insurance denials. With our help, you recover more and save valuable time.

At the point the client contacted ORI, it wasn’t clear why the insurance provider was claiming the clinic physician was not registered as a Medicare provider.

Research. Through our research we found a re-pricer was the one who was not recognizing the clinic physician’s status. Our process, once the problem had been clearly identified, involved:

  • Gathering information from the clinic stating their physician was indeed a registered Medicare provider.
  • This initial verification was sent on to the insurance company.
  • ORI staff followed up with the re-pricer to be sure the clinic doctor had been added to their verified list of Medicare providers.

It was at the point of follow up when we discovered the re-pricer never showed receipt of the verification paperwork. We re-sent the documentation only to have the claim denied again on the same grounds. The documentation we provided was not accepted.

ORI ultimately worked directly with the physician who was able to find their letter, from Medicare, proving they had been accepted as a Medicare provider.

This third round of documentation was sent to the re-pricer and follow up calls were made to ensure they had received the information.

Getting Paid. Ultimately, the physician was recognized as a Medicare provider. The entire process cycle lasted from March of 2010 – October of 2011 when the claim was paid. The claim covered a total of six dates of service.

Insights into the issue:
Keep important documents such as letters from Medicare.
Find out early in the dispute process where a claim is being “held up”.

Outsource Receivables Incorporated (ORI) applies a team effort to problem solving with daily 15 minute huddles and “stuck-ons” to share issues with the team. With so many complexities in professional medical billing it is truly important to have a team (we call “the entourage”) to rely on. Because we work with independent medical practices across the Midwest – Minnesota, Iowa, Wisconsin and other states – we have the depth and breadth of experience to solve problems that get our clients paid.

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