Medicare Compliance & Reimbursement

Pay attention to EOBs and keep talking to your MAC.

You could be losing money to a computer glitch and not know it, experts say.

If you don't nip a computer glitch in the bud, you may be plagued with improper denials and other claim holdups. Here are seven things you can do to seek out and solve glitch-related problems:

Watch your explanation of benefits (EOB) forms, and keep your eyes open for denials and downcodes that don't look correct.

Always review your accounts receivable (A/R) to ensure that you've received the payments you're due. If a computer glitch kept your MAC from paying you, don't hesitate to point it out to the payer.

"If we have any claims outstanding for 30 days that we sent electronically to that carrier, we contact the carrier right away," says Ginny McManus, billing manager with BergerHenry ENT Specialty Group in Pennsylvania.

"If we are told there is no record of receiving the claim(s), we will rebill immediately," McManus says. "It is definitely up to the practice to catch these problems. I have run into this scenario before and the carrier has never automatically reprocessed any of our claims. Good follow-up is everything in a billing department."

If you contact the MAC and the representative tells you that the payer plans to reprocess all claims affected by the glitch, always recheck that they've followed through. "Once I've submitted the claim, I will have our collector call back in two days to see if the claim has been received by the payer," says Kathy Philp, CPC, director of billing with Praxis Health Group in Oklahoma City. "I have the collector explain to the representative that they have by law to pay within a certain timeframe, which is usually 30 to 45 days, depending on the state."

In many cases, the insurance company will not reprocess the claims, and you'll have to resubmit them. "In that case, I would have the collector speak to a supervisor to find out whether they will deny the resubmitted claim as a duplicate, which would cause further delay in payment," Philp says.

Philp recommends calling the insurance companies two to five days after electronic submission. "Even if the claim goes to your clearinghouse, that doesn't mean it has gone out to the insurance company, because claims usually go to another clearinghouse before they get to the proper insurance company," Philp states. "Collectors should understand how the submission to a clearinghouse really works -- claims are submitted to other clearinghouses and insurers."

If the MAC experiences a computer glitch, "then you need to follow the trail to find out where it started -- was it during transmission, or is the insurance company stating this as a stall tactic and delaying payment?" Philp says.

5. Rely on Web Resources

Watch your carrier Web site. Some carriers that have experienced computer glitch problems have put up "error resolution reports" on their sites. You can look up each problem and see an estimated date for repair. If that date has passed, you should resubmit any claims affected by that glitch.

Visit your CMS regional office if necessary. If the carrier is denying or downcoding claims improperly and isn't responding to your complaints, you should take the matter to your regional office of CMS.

When you contact your MAC, make sure you get all of the information you're seeking before you end the conversation.

"I would recommend to anyone trying to collect from their insurer to be firm but nice and don't let them run over you, because they will if they think they have the upper hand," Philp says. "It is sad that we have to fight so hard to get the money that is owed to us."