Calling Provider Services Isn’t the Most Effective Option for Your Billers to Work Claim Denials

Do you, or your biller, anticipate a headache when you call the provider customer service team at a health insurance company? What if I told you that 99% of the time, provider services is not the appropriate area for your claim concerns?

How frustrating is it to call a health insurer looking for an answer to what you thought was a simple, straightforward question, only to end the call without a substantive answer, and maybe even more questions?

If you take a look at biller threads on Reddit, Quora, Facebook, etc. there’s a common sentiment that customer service doesn’t always know the answer to your question & when they do know, they’re not at liberty to tell you. Finding the answer turns into a game of guesswork, multiple calls, internet searches, social media outreach, or accepting the unknown. It’s confusing at best, and clearly underscores the need for a different approach.

Before you pick up the phone, keep the following in mind.

1. For most concerns there’s a dedicated provider-facing department

In healthcare, it’s a misconception that the provider service team is the primary go to for all questions. When in fact, they are best equipped to answer general questions that can also be found in printed material or on the website. The primary goal of the department is to manage call volume, not in-depth, investigative research. To save time, energy, and get a more detailed response, direct your question to the correct area.

2. It’s not an apples to apples conversation

When billers call they are attempting to understand why a service was denied & how to get the service paid. However, service reps are not trained in billing or coding practices. They can advise whether the claim processing went through the intended steps and logic checks. And they can read back the denial & any additional notes recorded during processing that are related to the application of the denial. But they aren’t resourced to know what procedure code, diagnosis code, or modifier could be appended that would allow the service to pay or if there are a variety of things preventing services from paying.

3. Addressing claims one by one takes too much time

For every denial, there’s definitely others that denied for the same exact reason. Instead of calling about individual claims, take a few minutes to list like denials & concerns together (i.e., lack of authorization, cosmetic, integral service). Once the root cause & how to address it is determined, apply that to the other denials in that same list. For example, if there are 2 billed E & M codes that consistently deny as integral, then you identify how to bill them correctly. Gather all claims with that scenario, re-bill, and submit the corrected claims. You’ll find it takes much less time and energy than calling the service team and inquiring about each claim.

Getting claim denials resolved doesn’t have to be distressing. In fact, you don’t even need to call as much as you think you do. Over the last few years, insurers have implemented more automated systems to reduce wait times & increase overall efficiency. Should you need to reach out to customer service though, you’ll have the most success:

1. When you ask general questions where you’re looking for direction and guidance rather than resolution
2. You’ve predetermined the point where the denial was triggered
3. By grouping similar concerns, in an effort to address multiple claims

Are you spending too much time spinning your wheels on the phone with Provider Services? MD Office Insights offers tailored services that steer health care administrators toward their revenue goal(s) – faster and easier than going it alone or outsourcing various pieces of the process. Gain maximum results with minimal effort, in the least amount of time.