Medical Billing Forum

General Category => New! => Topic started by: lori50851 on April 25, 2018, 09:01:10 PM

Post by: lori50851 on April 25, 2018, 09:01:10 PM

I am a new billing specialist that works for a non-profit OMH organization for people 55 +. The person that works at intake is currently (and for the past year) working P/T in billing to help keep up, . However, I found a LARGE amount of claims that were stuck in the clearing house due to invalid Member Id and no prior auth. for the past year. No one ever looked into the rejection folder before myself. These are claims for mostly Fidelis Medicaid, Empire, United Health and Healthfirst. Fidelis told me to write a letter stating we had issues with our clearing house and to write a letter stating that with the proof we did submit on time. My question is do I admit in the letter, we received a rejection but nobody in our organization checked the file on Ability or that intake made an error with ID #s and forgotten pre-auths? How can we get paid? My supervisor is very upset about the amount of unpaid claims.

Also, my boss gave me a project to see why the amount billed out is less then 50% from last year for Medicaid. They seem to be all cross overs from Medicare/Medicaid and the CPT is generally 90834 and 99215 and EM Code Level 4 or 5. Does anyone know how claims are pulled into "batches" using AWARDS? I must be missing something, because we see the same # of patients per/day and the amount of money billed out is way TOO small for Medicaid. Is Awards not "batching" those with invalid Ids? or non-pre-auth?

My finale question, is it the Member(patient) that must declare the primary/secondary insurance for the COB?

Post by: Michele on May 01, 2018, 12:59:18 PM
This is an unfortunate situation.  The insurance company's rationale is that the provider is responsible for the claims being submitted on time.  Even though the provider had no idea his staff wasn't checking the clearing house reports, they feel that he should.  The provider was notified that there was an issue and didn't do anything about it. 

But, we have seen where some insurance carriers make an exception for a provider based on circumstances.  I would do up the appeal.  Personally I don't think I would mention the rejections.  Just show the proof that the claims were submitted.  They may allow based on the fact that they were originally submitted timely even if the reports were not acted on.  Contact each insurance carrier and ask what you can do.  If there is a provider rep, contact them.

I am not familiar with AWARDS.  Maybe try contacting customer service to see if they can help you?

Not sure what you mean by "declare the primary/secondary" insurance.  Do you mean notify the provider's office?
Post by: PMRNC on May 01, 2018, 01:22:00 PM
Are these ERISA claims? If so that might make a difference with timely filing.