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A Serious Question

While some may find this question laughable, it is in fact a serious question that is relevant to our denials management process.  Sometimes insurance companies send denials remittance information back to providers that are inconsistent. Occasionally we know that payers don’t tell the truth, aka they lie. I know this may be a sensitive subject for some to call them out explicitly, but if you’ve been in the field of revenue cycle management aka medical billing for a long time, it’s pretty well established and known that insurance companies frequently do not tell providers the truth…also known as lying.

Sometimes insurance companies say that there’s no claim on file when we all know that they received it. Other times they may deny claims for some completely inappropriate and fictitious reason. These are thinly veiled and not even plausible excuses for why not to pay it.  Everyone knows they lie, it’s an accepted truth in the industry.

In denials management there are a set of codes and a set of descriptions to explain the rejection or denial. The codes and descriptions are set by a governing body in order to standardize them to facilitate claims submission and payment, at least in theory. However, there is typically a written description of the remittance that comes from each payer. Some insurance companies don’t provide this information, but most of them do in a text format. It may be that the information is buried in a long string of other numbers letters  that you have to extract by parsing the field data, but it is in the data from most payers and clearinghouses. Most billing systems (practice management systems, laboratory information systems, hospital information systems, and so on) are not capable of retrieving this information.  Therefore, in order to access it, you may need a workflow automation tool or do something similar in order to retrieve it.

This information can be useful in performing denials management and analyses.

Trouble in Paradise

Interestingly, sometimes the information provided by the payer is discordant and confusing.  In other words, what you see from reason code and the reason description for that remittance may not match.

A denial with code CO133 might typically have a description “that the claims are under review”, but then some will have a reason description that the “claims are pending”.  What do you do?  The description doesn’t match the code and the written reason suggests that there is nothing for the provider to do and that they’re in the process of being paid.  Just sit back and wait for the money to come in, right? 

Some of those CO133s will say that they’re in clinical review, which might indicate that you need to submit additional documentation. So which is it?  Those are all entirely different things and would have the provider take different action (or no action) depending upon what is to be believed.  A CO17 denial might state that the claim was denied from some payers, that the payment was adjusted from other payers, and still others might state in the description that they are requested additional information and that information was not yet received.  Wait…what?

Even worse, we we may see denials that have a remittance code of CO11 and the overwhelming majority will have a description that either matches exactly the lookup table or have something similar to “the diagnosis is inconsistent with the procedure code”.  However, then there is always a subset that have a completely different descriptions sent by the payer for a CO11, for example that the “maximum benefit has been reached”. Confusing? It gets worse.

What’s a Medical Biller to Do?

When you are trying to do denials analysis, how do you group these things into clusters to take action? How do you deal with variances in descriptions? How do you deal with completely conflicting denial codes and descriptions? 

How do you decide what to do, and more importantly, if you think the payers are telling the truth or are giving you accurate information that might lead you to different behavior? If you want to use the information that comes back in denials and remittance information to fix claims, update claims, resubmit claims, appeal claims, you might be wasting your time or the time of your team. Or you might be losing a lot of money if you use that information and the payers aren’t consistent or telling the truth.

Let’s break this down – even if the payer remittance code and description are completely consistent – is it the truth?  We know that no claim on file is a complete down and dirty lie, but what about other codes.  Most billers believe the remittances given in the hope that solving that problem will result in payment.  This is very often a false belief.

The example that we’re going to use. In this case is CO109, indicating that the claim was sent by companies to the wrong payer. Many payers will send remittances back, saying, “…incorrect payer. Please, resubmit to the corrected payer.” Other payers will send a remittance back saying, “…the wrong payer. The claim has been forwarded on to the appropriate payer.” The question is whether or not you can trust the payers who say they forwarded it on actually to do so, or whether you still need to do all the work to resubmit the corrected claim to the right location.  This includes getting updated demographic information from either the patient or chasing the referring provider to get updated information, then re-checking the eligibility for that new patient insurance information to ensure it is correct, and then resubmitting it to the new payer.

Hobson’s Choice?

The critical question is, “Can you trust them?”  Is the information they are providing reliable or do you have to verify everything yourself and potentially do a lot of extra work?  For this specific example of whether they forwarded the claim on to the correct payer, if you trust the insurance company and they’re not telling the truth, you’re going to lose a lot of money because you didn’t submit it to the right payer upon follow-up.  This means nothing will ever happen or once you realize the issue you may have already missed a timely filing limit. However, if you don’t trust the payer, that creates a massive amount of work on all of those claims where you must chase down new demographics and related processes. That is thousands or even tens of thousands of claims multiplied by a lot of work per claim, depending on the size of a provider, or in some cases maybe even hundreds of thousands of claims every year. 

And this is just for one type of denial.  Try extrapolating this concept and its impact on workflow across all denials.  If you have to validate everything that comes from a payer it would be an overwhelming amount of work.  Who has time for that?  You may be left with a choice between lost revenue and an insurmountable workload. Is this really a choice?

We’re going to follow up and find out. We’re going to do an analysis specifically for companies of the remittance code CO109. We are going to find out if they are telling the truth. Stay tuned! In a follow-up article, we’ll let you know the results.


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