Sending Tracers/Follow up on EDI claims

[dfranklin]

What is the standard procedure for following up on claims (Electronic) that were confirmed but ERA's were never recieved?  Do you resubmit the claim again? Do you send out a letter? Or do you have to call on each one of these?  THere can be ALOT that seem to not get a response (they get confirmed that they went out and recieved but then they may not get an ERA...

[Anand]

What is the standard procedure for following up on claims (Electronic) that were confirmed but ERA's were never recieved?  Do you resubmit the claim again? Do you send out a letter? Or do you have to call on each one of these?  THere can be ALOT that seem to not get a response (they get confirmed that they went out and recieved but then they may not get an ERA...

Personally i would shy away from just re-submitting the claims because i dont think it would add any value.. but i would certainly give some time frame because the processing time varies for each payors. I would take my call based on the time frame and f/u if needed. When claim goes thru electronically if there is no corres from ins after resubmitting twice, i would think before just filing it for the third time. I think its a better idea to f/u with ins and enquire if all t' and e's are checked and crossed.

[Michele]

I would shy away from resubmitting as well.  If the claim was processed, but the ERA is out there somewhere but not received by you, it will deny as a duplicate.  Some insurance carriers look at duplicate submissions as a reason to audit providers. 

What clearinghouse/method are you using to submit them?  For example, Office Ally allows you to see the claim after it is submitted and provides reports on if claim was accepted.  If all of the info points to received and accepted, I would call to find out why the insurance carrier isn't paying.  It should be a fixable situation that may ultimately eliminate this from continuing.  It concerns me that you are getting 'a lot' with no response.  Do you get the reports on your electronic batches and are they being read properly?  That is a major problem for many.  In any case, I personally would want to get to the bottom of why there is no response.

Michele

[dfranklin]

What is strange is that it is not one particular provider or patient and in fact one patient has some payor processed with ERA recieved and others for the same patient are still just sitting there...and it is intermittent...say 7/1 was payor processed 7/7 is not 7/9 is 7/15 & 7/17 not then there might be a bunch that are and then a bunch that are not...time has definately passed because I have received ERA's on more recent claims as well....it makes no sense why there are so many not coming back payor processed.  Some that I have called on I found that they had no record of the claim...but why wouldn't there have been an ERA or someother response?  Especially when it has been confirmed by EDI?

EDI is Gateway. Software is Practice Admin.  It will show "EDI File Confirmed" and "EDI Claim Confirmed". And I just opened a ticket with support to see if there is a problem.  I haven't resumbitted even a second time in most cases, just the one. But I read somewhere (I think it was on CMS or maybe a webinar) that if there is no response the 1st time to resubmit a 2nd time (if a long enough time period has passed which in these cases there has been).

[PMRNC]

I'm going to disagree with every one here because I was a claims examiner.. sending a tracer will only prompt the carrier to deny needing the claim if they never received it to begin with. I will do my claims follow-up and resubmit claims if I need to except for Medicare (they don't like too many duplicate claims)

When I do my follow up, I have a sheet in front of me to note when and if the claim was processed, outcome/status, payment if any, check number if any, because MOST times the provider done forgot or neglected to send me the EOB. I charge a penalty for that (my time) when it happens.

[Michele]

Do you get a penalty fee for every eob that you don't get?  Or do you give them a certain amount before you charge?  This is one of our pet peeves as well.  Nothing worse than wasting your time calling on a claim that the provider got the money for.

I don't ever send tracer either, but I don't usually just resubmit without calling.  Especially with what you are describing.  It really sounds like their is an issue that needs to be resolved.

Michele

[PMRNC]

I bill on a monthly basis and my monthly fee includes my time but not for time not otherwise spend on an account such as incidents like that. If I have to chase down payments that the provider received but didn't notify me of by sending me the EOB that's time I could have spent on other things and normally would not have had to spend on his account so I will bill him for the "time" If it's just one every once in a while, I don't really bother, but I do have a few that are habitual offenders so I will charge them for every single one. <g>

[Michele]

Interesting, thanks for sharing!

[PMRNC]

I'm in the middle of compiling an invoice for a provider who's Office manager is also the doctors wife, a month ago she started stacking the mail and taking it home with her, cashing the checks and I was left with 78 claims to follow-up on to chase down the payments. This happened in past and the only thing the doctor says is "She does go on spending spree's at spur of moment"  Well he's getting billed for my time in tracing those 78 claims!

[Alice Scott]

Good for you.  We are changing our contract. 

[melissa_2004]

I'm in the middle of compiling an invoice for a provider who's Office manager is also the doctors wife, a month ago she started stacking the mail and taking it home with her, cashing the checks and I was left with 78 claims to follow-up on to chase down the payments. This happened in past and the only thing the doctor says is "She does go on spending spree's at spur of moment"  Well he's getting billed for my time in tracing those 78 claims!

This is a really good idea.  I just spent a lot of time over the last week trying to track payments for a client only to find out the insurance company is keeping the payments and applying them to a recoupment of claims billed last year before I began billing for them.  A report was sent listing all the claims this applied to but it never made it to me.  This is a perfect time for me to update my contract as I'm already working on other documents with my attorney.

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