Best Practices for Healthcare Organizations: Contacting Insurance Payors on Unpaid Claims

Managing the revenue cycle efficiently is critical for healthcare organizations. One of the most challenging aspects of this process is dealing with unpaid claims from insurance payors. To ensure that your organization maintains a healthy cash flow and reduces the time accounts receivable are outstanding, it's essential to follow best practices in contacting insurance payors regarding unpaid claims.

1. Establish a Clear Timeline for Follow-Up

Creating a clear and consistent timeline for follow-up on unpaid claims is crucial. Here is a recommended schedule:

• Initial Submission: Submit the claim as soon as possible after the service is provided, ideally within 24-48 hours.

• First Follow-Up: Contact the payor within 15-20 days after the claim submission if no payment or communication has been received. This allows time for the claim to be processed and any initial issues to be addressed.

• Second Follow-Up: If there is still no response or payment, follow up again within 30 days of the initial submission.

• Subsequent Follow-Ups: Continue to follow up every 15 days until the claim is resolved.

2. Utilize Electronic Tools and Portals

Many insurance companies offer electronic tools and provider portals that allow healthcare organizations to check the status of claims. Using these tools can streamline the follow-up process:

• Claim Status Inquiry: Regularly check the status of your claims through the payor's electronic portal. This can provide real-time information on the processing status and any required actions.

• Electronic Remittance Advice (ERA): Review ERA documents promptly to understand denials or adjustments and address them quickly.

3. Maintain Comprehensive Documentation

Document every interaction with the insurance payor. This includes:

• Dates and Times: Record when you submitted the claim and each follow-up contact.

• Details of Conversations: Note the names of representatives you speak with, their responses, and any promised actions.

• Claim Corrections: Track any claim resubmissions or corrections, along with the reasons for adjustments.

4. Develop Standardized Communication Templates

Having standardized templates for communication can make the follow-up process more efficient and professional. These templates should include:

• Claim Details: Include patient information, claim number, date of service, and amount due.

• Action Requested: Clearly state what you are requesting from the payor, such as payment status or reasons for delay.

• Contact Information: Provide your contact details for easy follow-up by the payor.

5. Train Your Staff

Ensure that your billing and collections staff are well-trained in the following areas:

• Payor Policies: Understanding the specific policies and procedures of each insurance payor.

• Effective Communication: Training in professional and effective communication techniques for dealing with payor representatives.

• Problem-Solving Skills: Developing skills to quickly identify and resolve issues that may be causing payment delays.

6. Implement a Claims Management System

Invest in a robust claims management system that can:

• Track Claims: Monitor the status of all submitted claims in real-time.

• Flag Issues: Automatically flag claims that are overdue or require attention.

• Generate Reports: Provide detailed reports on claim status, follow-up activities, and payment trends.

7. Escalate When Necessary

If repeated follow-ups do not result in payment, consider escalating the issue:

• Supervisor Involvement: Request to speak with a supervisor or manager within the insurance company.

• Formal Appeals: File a formal appeal if the claim is denied without a valid reason.

• Legal Action: In extreme cases, consult with legal counsel to determine if legal action is warranted.

Conclusion

Efficient and effective follow-up on unpaid claims is essential for maintaining the financial health of healthcare organizations. By establishing a clear timeline, utilizing electronic tools, maintaining comprehensive documentation, and training staff appropriately, you can significantly improve your revenue cycle management. Implementing these best practices will help ensure timely payments and reduce the administrative burden on your organization.