In the last podcast, we talked about the blame game and the challenges associated with it. When there’s something wrong in billing, how do you identify who it was and who’s at fault? And how do you deal with that issue?

The insurance company screwed it up, the billing department or the billing company. Screwed it up, or the front desk and eligibility patient intake. Whatever that department is, they screwed it up. How do you deal with those issues? How do you find out who’s responsible? Do you thread that needle of dealing with that, where you get into the “he said,” “she said,” or the blame game, and nobody wants to take responsibility for anything?

I’ll share what we did when we had a billing company because we ran in this so often, and a lot of times, our perception was that it was something that was outside of our control. We had not screwed it up. We perceived ourselves to be an excellent billing company. Indeed, the data that we had seemed to suggest that was the case. However, that didn’t change that many clients would blame us when something went wrong, even if it were their fault. Even if it was outside of our control, the insurance company did something; the assumption was that we’d done something wrong.

Enrollment Package

One of the favorite ones at Hammer was we sent something to one of the state Medicaids. I want to say it was an enrollment package. The weeks and weeks and weeks go by, and they kept saying that they hadn’t received it. So we played this game where we sent it multiple times. We sent it as certified mail. Eventually, we had a situation where the insurance company, the Medicaid program. Was saying, “Hey, we didn’t get it.” We said, “Well, your name is Barbara, and we have a signed piece of paper from you that said you got it. This is your name on the return receipt. You personally got it. We know you got it.”

There are always so many times that you can’t prove that you did something, and it drives you crazy.

I’ll tell you what we did. We built a system to capture track responsibility of claim problems.

Tracking claim problems

Let’s say, for example; there was no claim on file. That there was some breakdown in our IT? The biller didn’t hit “Submit” on the batch or something like that? Or the clearinghouse broke down and never sent it through? Or the insurance company had some problems, they didn’t get it, or maybe they got it. But they’ll claim they never received it? One of those games where they throw things in the garbage, or something more complex.

Where maybe they’re not the right insurance company and, therefore. Even though they received it, it’s, quote, “Not on file” because it wasn’t considered to be the right one? Or worse, they are the right insurance company, but they had the wrong address, even though it was an electronic claim, which is the dumbest thing on the planet? They get to pretend that they didn’t get it because you didn’t have all the right information there. And maybe, the clients gave you the wrong information or perhaps the front desk or patient intake, whatever it is.

A Data Collection System

Whatever those were, we then built into a data collection system that fed into our analysis. Where it allowed us to put in the second level of problem-solving. The stated reason was “No claim on file,” and we had a second-level root cause analysis. When our billers were trained to follow up and identify what the root cause was. After “No claim on file,” they would say there was an EDI problem or that the patient or the provider was no longer enrolled. Or that they sent it to the wrong insurance company, or that the patient eligibility wasn’t done correctly, or the patient’s name was fat-fingered, or the NPI or the patient ID was given to us wrong, or whatever it was. It was a long, long list of things like that. But it was in a drop-down menu so that you didn’t have categorization problems.

How to solve billing problems?

We were proactive in using this. When we captured all this data, it helped us solve problems. Because it helped us get to the root cause. Then, of course, many of us go back to clients and show them that, “Hey! The insurance company is screwing up. You guys are screwing up, and we’re screwing up. We’re all screwing up, but it’s not 100% us. Here are the ones where we screwed it up. And here is the ones where an insurance company did, where you guys did.” We could go through and then bring to them, “Hey! Here are 50 examples of where eligibility wasn’t performed. By your front desk correctly, even though they said they were doing it.”

What we then did was allowed us to put them on the spot. Where if they’d assumed we had all these problems in terms of denials. And it was our fault, we could then say, “Okay! Therefore, if you don’t fix them at this time, we’ll continue to get denials. Which will be problematic for you because you’ll be losing money. It’s also a problem for us because we’re cleaning up the mess after the fact. And we shouldn’t be cleaning up your mess. If it does continue past that point, then we’re going to do that automatically: we’re going to take over that process ourselves. Like the eligibility checking, and we’re going to charge you for it.”

Several Things

That meant that several things happened. One was because we were tracking and showing to the heads of practices. And provider organizations those problems that were in their wheelhouse. It typically meant that they got better because there was no data instead of just finger-pointing. Therefore, they could go to their own organization and say, “Here’s the problem, and here’s the quantification of the problem. And here are examples.” That changed the game from “he said,” “she said,” blame game kind of stuff, to “we’re dealing with data,” and it made it much more objective.

Deal with data efficiently Billing

Most of them got better. That helped us significantly because we had fewer problems to clean up on the back end. We also had better customer satisfaction, and customers understood that not all of the billing issues were our fault. That meant that our costs were lower, and our profits improved. We had all kinds of benefits associated with doing that.

I wish it were always that simple. The reality is that there’s always going to be conflict and finger-pointing: a practice manager or a CEO of a provider organization gets angry, or somebody in some organization is upset because we blamed them effectively when we showed that they were screwing up, or their ego doesn’t allow that, or maybe it’s a fragile organization internally, where heads roll when somebody gets upset, or it’s a doc that screams.

Launch An Investigation Internally

We’ve seen this go particularly badly. In one situation, we had a client who accused us of fraud. Of course, that freaked us out for a combination of reasons. We had to sort of launch an investigation internally to ensure somebody in the organization wasn’t cashing checks. Sort of scrambled head trying to figure out and make sure, “Hey! We got to make sure somebody isn’t doing something untoward within the organization that we’re not aware of.” What it turned out was the client had an internal liaison who had a billing background, and they wanted to take the billing back in-house and become the billing manager and hire all those employees. So they essentially made some claims that were not true.

It worked. They took the billing back in-house because top management, one doc, and a doctor who owned this provider organization were a little bit volatile. He believed it, and so they took it in the house. The billing got worse, and they lost their Vice President of Sales and Marketing because they couldn’t get paid enough business to keep the sales reps happy, so the VP left after that happened. A little bit of vindication that made us feel better.

False claims

The point is that finger pointing is going to happen. You got to have excellent data to identify where the problems are, who’s responsible so that you can have an objective conversation. It’s not “We’re defensive,” “No, it’s not our fault,” “Nothing’s ever our fault,” but here are the numbers. Here are examples. Here’s what we do about it.

We told that client to stick it when they’d given us a fraud because I’m not mainly a big fan of infamy. Life’s too short of having somebody accuse you of something illegal, much less something unethical. Your reputation does matter.

We’ve never heard and never found out whether there was a fraud, or there was just a claim of fraud or somebody inside the organization. Was committing the fraud or what because we separated. The whole wing, we cut off that very quickly after that happened. They took it in-house, and we cut all ties very quickly.

Billing Department

Whether it’s a billing company or a billing department, for the most part, we want to believe that we’re doing well. Or an outside billing company will be defensive and say it wants to do well, and things won’t get better. You need data to be able to figure these things out.

Even another idea that’s a little bit radical and this is a role we’ve sometimes played, is you can have a third party that can effectively arbitrate these issues or says, “Okay! Yeah, no! That was the insurance company that screwed it up,” or “No! That’s the provider screwed it up,” or, “Hey! The billing company screwed up.” They need to take responsibility even though they’re not. That can help relieve some of that pressure.

That’s our suggestion in terms of how to solve that blame game. We hope that’s helpful for you!



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