Getting Claims Paid Takes “True Grit”

Getting Claims Paid Takes “True Grit”

By Cindi Lignell, Account Executive

To someone looking at the website, eAssist is a dental insurance billing entity that helps practices with the big job of ensuring claims are paid at the maximum allowable in the shortest amount of time.  But really what does that mean for the eAssist workers behind the scene every day making sure that claims get paid? There is an old saying “Don’t judge a man until you walk a mile in his shoes (or her shoes).”  If some claims seem to take forever to get paid it is because of the myriad of details that must be attended to for satisfaction of the insurance payer.   Each and every insurance billing account manager or account executive has one or more “worst claim” stories of what they had to do to get the claim paid. I am very sure that many dental practices give up and either bill the patient or write off the amount for fear of losing the patient.  eAssist takes that claim and “shakes” it to get it paid. The following is a story that I want to share about one claim that I had success in getting paid but not without a lot of time and grit.

The claim was for an abutment crown on Tooth #12, and a crown on tooth #13.  The patient had dual insurance. The patient had maxed on his secondary insurance, but we needed the EOB to properly adjust the claim according to both Prime and 2nd insurance EOB’s.  X-rays and EOB were sent with the original claim.

When the claim was over 30 days aging, I spoke to a rep who said they had the claim, but needed x-rays.  I stated that they were sent, but the rep did not see any. I resent the claim with x-rays and the claim number by mail.  I resent the x-rays again 3 weeks later when an online search still showed they needed x-rays. 2 ½ weeks later we received an EOB requesting the date of extraction for #12 and initial placement date for #13.  (These dates should have been on the 1st claim.)  I faxed the requesting EOB with the dates.

2 weeks later an online search showed they needed the primary EOB, which I sent again by fax. 2 more weeks and online still not showing they received the EOB.  I spoke to a rep and faxed the prime EOB with the requesting EOB directly to his fax while he waited to receive it. It was a 48 minute call!

2 ½ weeks later online still showed they needed an EOB.  I called the insurance and the rep could not find the EOB I sent! I spoke to a supervisor and faxed the EOB directly to him.  He promised to call me when he received it. I never received a call.

I spoke to another rep who said they had all the info and it was in review and would process within a week.  I called 2 weeks later and was told by a rep that the claim was unprocessed and he would send it to reprocess.  I told him no! Absolutely not! I requested a supervisor, stating I was not willing to wait another 2 weeks for it to reprocess when I was told it would be paid by now.  After a lengthy hold time I spoke to a supervisor who promised to escalate the claim and have it paid in 3-5 business days. She promised to call by the end of the week to let me know it has been mailed out. I never received a call.

A week later I called and asked if the claim had processed.  Yes! When I asked for the date the EOB went out, she said it was actually still processing, and that they needed an EOB.  I could not believe my ears.  I stated that they had received everything from us and should process to deny the claim due to maxed benefits.  I asked for a supervisor and was disconnected.

I called back and demanded a supervisor.  The supervisor researched and found the EOB, extraction date of #12, prior placement of #13, and x-rays. Between hold for the supervisor and waiting while he searched for the info, I was on the call for 1 hour and 16 minutes.

After sending the claim/info 8 times, and 7 phone calls, the claim was processed and denied as maxed.  It was adjusted and closed. For me, it is all in a day’s work.

eAssist Helpful News and Billing Tips; Edition #122

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