Author Topic: Claim Pending - Requesting information from Patient  (Read 2212 times)

barcafan1990

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Claim Pending - Requesting information from Patient
« on: January 27, 2015, 02:38:08 PM »
I frequently run across this situation where we submit a claim for a patient (usually its a new patient that we have never submitted for) and the insurance (Aetna commercial in this case) pends the claim until "requested information from the patient is received." When I speak to an Aetna representative they usually say its a questionnaire that the pt needs to return to verify their Coordination of benefits (i.e. "Do you have any other insurance that could be primary?").
The frustrating thing is that we also submitted a claim 10 days later because the patient had their Annual Wellness visit done. This claim was paid but the Aetna representative says they still can't process the first claim that pended for COB verification. How can this be right? I tell them "Then why did you pay for the other claim that was submitted 10 days after this one that you pended?"

How do you all handle these situations?

We do all of our billing in house because we're a solo-doctor's office. We don't have the resources to call patients and ask them to call their insurance back/return the questionnaire that they're requesting so we just send them a bill saying that they're responsible for the entire visit. This motivates some of them to call us or the insurance company and figure out what's going on.

I'd appreciate your feedback though.
Josue M

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Re: Claim Pending - Requesting information from Patient
« Reply #1 on: January 27, 2015, 03:06:01 PM »
Do you have a financial policy? If so it should include terms for when this happens. With the ACA you also have to take into account the grace periods so it is really a good idea to review your financial policies.   Our policies state that we require payment on balances within 30 days.. PERIOD. If their insurance has PENDED charges for example for COB info, etc.. we still require payment within 30 days. When we have a charge that is pending for the COB info from carrier we send patient a statement and a message that their insurance is awaiting information.. but regardless they have a patient payment due date. We have a lot of these. It's a pain, which is why I suggest ONE office financial policy which has this in it.
Linda Walker
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rdmoore2003

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Re: Claim Pending - Requesting information from Patient
« Reply #2 on: January 27, 2015, 03:10:51 PM »
This is just part of insurance.   If I understood correctly, they paid on the second claim because it was for annual wellness.   I fully understand that you may not have the time nor the "manpower" to call this patient, however, you should.   The patient can call the insurance and give them the information over the phone (Unless, the insurance company has specifics, but I have not found one yet). 

With all of that said, if the patient does not respond to the insurance company and does not pay your office, this is when it all falls to your office paperwork.  If your office paperwork is up to date and covers this type of issue, and the patient signed it, your covered.   By this, I mean, covered to take collections efforts.  My state allows collections company to charge an additional 35% to the account.   So if your patient owes, $100 and does not contact the insurance, you bill them your standard bills for your standard amount of time (I send 3 invoices then a collections letter).  If not handled, that $100 turns into $135.00.   

Again, I fully understand about not having enough staff and/or time, but you still NEED to call the patient, if nothing else, just for documentation purposes.
Regina

kristin

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Re: Claim Pending - Requesting information from Patient
« Reply #3 on: January 27, 2015, 07:05:21 PM »
Agree with points both Linda and Regina made. Have a financial policy in place that states how long you will allow insurance to process a claim, how long the patient has to pay the balance, and what happens if they do not. In my office, we give insurance 60 days to process a clean claim, then it becomes patient responsibility. The patient has 28 days from the date of the first statement to pay us, then the next statement if the balance is unpaid has a $20 rebilling fee added. After the second statement, if payment is not received, the balance is sent to collections with a 35% collection fee added, but ONLY after I have made a call to try and collect the money first. All of this happens unless prior payment arrangements are made with me by the patient. And all of it is spelled out in our financial policy that each patient signs when they first become patients.

Luckily, we have great patients, who pay their bills promptly, and respond to requests from their insurance, so if I send 5 people to collections in a year, that is a lot for me. Last year, I sent no one. I do realize that is not usually the case.

As far as not having the time to call the patients about things like this COB issue...you have to find a way to make the time. I also work for a solo practice, and do everything in-house also. We are very busy, and it is just me, one back staff, and the doctor. As busy as I may be, I absolutely can make the time for a 3-5 minute phone call to a patient about something like this, which costs my boss FAR less for five minutes of my hourly wage to do, then sending a statement would cost for something like this. Industry average says sending a statement costs, like, $5-10 per statement when you factor in supplies, postage, and employee time. Versus what...roughly $1.50 to make a five minute or less phone call? The phone call is cost-effective, the statement is not.


barcafan1990

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Re: Claim Pending - Requesting information from Patient
« Reply #4 on: January 28, 2015, 11:16:23 AM »
THank you all for your responses. I must agree that we do need to find the time to contact patients as it will resolve things quicker and at a smaller cost. And we also do have a financial policy on our 'Todays Visit" form that we have each patient sign at every visit which basically states they are ultimately responsible for unpaid balances once we make our best effort to collect from the insurance.

My main concern here was if there was anyway around these pending claims for COB because they are so frustrating. However I understand that they happen so we just have to work with the patient. I just had to vent a little. But thanks again for the advice.
Josue M

kristin

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Re: Claim Pending - Requesting information from Patient
« Reply #5 on: January 28, 2015, 01:35:55 PM »
I know of no way around COB issues. That is between the patient, and their insurance companies, and only they can fix it. We see it a lot when patients first switch to Medicare, and Medicare still thinks they have commercial insurance as primary.

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Re: Claim Pending - Requesting information from Patient
« Reply #6 on: January 28, 2015, 02:48:36 PM »
Doing Ped's we have to deal a lot with COB requests pending at carrier, so we actually will ask the parent when they come in if there are any changes to their carriers or employment, if we can catch a potential COB pend before it happens it's better. Also if you contact the patient and ask them "We see your insurance carrier is holding our charges for information they requested from you, can we help you with this so you don't have to come out of pocket for the whole bill?"  That usually does the trick. We just get lucky to catch a few before it happens and we have a form we give to patient to complete and we send in with their claim if they changed employers. contains all info carrier would need to check other benefits.
Linda Walker
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barcafan1990

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Re: Claim Pending - Requesting information from Patient
« Reply #7 on: January 28, 2015, 03:06:30 PM »
I always assumed that insurance carriers pended claims (for COB) as a trick to not have to pay it until the first time a provider submits a claim to them. Not then do they conveniently verify that they should be paying. And as Kristin said I didn't think there was a way around this. But Linda, I am curious to know more about the form that you use to proactively "help" the insurance carrier with COB. Could you share what other details it includes that is not already included on the claim? And how do you attach these electronically to claim batches, or are you mailing these in via paper?
Thanks!
Josue M

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Re: Claim Pending - Requesting information from Patient
« Reply #8 on: January 28, 2015, 03:50:07 PM »
Quote
I always assumed that insurance carriers pended claims (for COB) as a trick to not have to pay it until the first time a provider submits a claim to them. Not then do they conveniently verify that they should be paying. And as Kristin said I didn't think there was a way around this. But Linda, I am curious to know more about the form that you use to proactively "help" the insurance carrier with COB. Could you share what other details it includes that is not already included on the claim? And how do you attach these electronically to claim batches, or are you mailing these in via paper?

Depending on patients plan, for dependents, they will require info once or twice year. For COB info they pend the spouses claims and dependents if the plan follows the bday rule and the insured's bday is after the spouses. If the spouse is not working, nothing further is needed. If the spouse is working they require information from the spouses employer about other coverage available. If another carrier has primary responsibility they of course won't pay the claim until the primary plan has been billed. Some carriers won't pend and will pay and issue an ROR (right of recovery) statement which says they have a right to recoup the funds later.  The form the front staff uses is basically just the first step, requesting the spouse's employer information and such. IF the spouse has other coverage and they can show it, then we can just bill primary and send in the info to the other coverage we had on file.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com