Worst Claim Story November 2019
Feb 2018, I had a patient that was seen for a recare appointment. The day of, Metlife confirmed their coverage. The claim was paid quickly, without any hiccups. However, 2 weeks later Metlife sent an EOB with $0.00 pay. I called and spoke with a rep to ask what was going on and he said it was a system malfunction, all was fine. A few weeks later, we received a refund request stating that they wanted the funds back because the policy retro termed. I called again to confirm. We issued a refund and reached out to the patient to update benefits. Apparently he was still covered by Metlife, just under a new plan. I verified and resent the claim with updated benefits. This time the claim came back denied stating patient not covered. I still had the printout showing patient was covered but couldn’t replicate in the Metlife portal. I called and said the patient had never been covered under that policy. We got the patient involved again and he confirmed with employer that he had coverage. The claim finally processed again, but we received yet another denial. The patient ended up paying for the appointment and let it be. March of 2019, he calls angry saying that we never submitted the claim properly, although we had proof from clearinghouse that we did. We sent all documentation from the clearinghouse, both claim forms, and even the EOBs from Metlife showing that both group numbers had been submitted. Because of the numerous changes in the patient eligibility, Metlife “lost” the EOBs. It took ~2 more submissions for Metlife to get it straight but they finally did and finally paid on the claim. When we took it to a supervisor they said it was just a glitch in the system and couldn’t explain it any further. Needless to say, a simple recare appointment was one of the most frustrating claims I have dealt with and it definitely helped prove the importance of downloading EVERY EOB from the portal. Without those, I wouldn’t have had as strong of a case for timely filing or proper submission. So save all of those EOBs and question EVERYTHING!
Dental Billing Tips and News for Pros; Edition #141