Practice Management Alert

Question: What steps should I take when an insurance company says it never received our claim?

New Jersey Subscriber

 
Answer: Dont try to argue whether the insurer got your claim. Instead, prove that you submitted it. When a provider representative tells you the company never received your claim, ask for the fax number and the name of the person you can fax the claim to, say that you are sending the claim again by fax that day, and then fax it. Keep your transmission reports as evidence that you sent the claim again. In the next day or two, call and ask the status of the claim. If the insurer still insists it hasnt received the claim, you have proof from your fax transmission that you indeed sent it and that it should be paid. Document all your telephone calls about the claims by recording the name of the person you talked to, the date and what was said.
 
The better you stay on top of claims that need follow-up, the more proof you are likely to generate that you submitted the claim. For example, if an insurer sends an explanation of benefits (EOB) that says the claim is in adjudication, that indicates it received the claim because the company is reviewing it. When you call to follow up later, you are told the company did not receive the claim but now its past the timely-filing deadline. The EOB proves that the company did receive the claim and that the claim was submitted in time, and you should appeal.
 
You can expect that at some time an insurance company will lose or misplace your claim. But if it happens frequently, you are right to suspect that the loss may be an attempt to delay payment. For example, an unscrupulous company may delay your claim because the company has paid out all the claims it can afford for the month, and your claim will fall into the batch slated for payment next month. If you send a batch of claims in a single envelope or in a single electronic transmission thats confirmed as received, and the insurer only receives half of them, that could be a sign of a deliberate delay in payment. You should follow up all your claim submissions and document all telephone conversations, fax transmissions and other correspondence on the missing claims. If you identify a pattern, file a complaint with your state insurance commissioner.