Marsha Sosebee

I started an incredible journey last year. One that I never thought I would have to take. In May of 2012 I found a lump at the base of my neck which was eventually found to be thyroid cancer. Thank God I am now cancer free, but having gone through the medical system as a patient I came away with some insight into the lives of patients that billers usually don't see or deal with.

Having been in the medical field for more than 20 years, you know I had scores of colleagues, coworkers, friends, and acquaintances who wanted to give me expert advice. I had people tell me their take on the situation or detail their story to me in detail by agonizing detail. Why is it that when something happens to you, everybody in the world seems to know all there is to know about what you should do or shouldn't do and feel compelled to tell you every "worst-case scenario" they have ever heard about?

So this is what I learned about how to deal with patients from being one myself:

1. Be careful what you say and how you say it.

I wanted people to be honest with me, but I also wanted more positivity that I was getting.

I didn’t want to hear things like, "Oh well if you're going to have cancer, thyroid cancer is the kind you want." So, "Um, no, I don't want any cancer, thank you very much," is what I wanted to say back to these hopefully well-meaning folks.

2. Don't make light of what they are going through.

Another common thing I heard was, "Oh, it’s just thyroid cancer." Anytime you say "it's JUST" this or that, you are belittling the seriousness of the issue being discussed. Yes I understand that thyroid cancer is not as life threatening or treatment intensive as some other cancers, but it is still cancer and still an ordeal with which you much come to terms.

You might be able to handle a certain diagnosis better than someone else. That fact does not lessen the impact of what they are experiencing.

3. Don't assume you know what they are feeling.

If I had a nickel for every time someone told me they knew exactly how I felt, I would be a millionaire. Everyone comes into a situation from a different vantage point and with different baggage. Each of us possesses a unique set of emotional triggers and a particular breaking point. Many things go into what feel during a medical crisis… … the external aspects of our lives at that given time, our personality, our previous experiences with similar episodes, our outlook on life, and our faith or lack thereof. Even if you have had the exact same diagnosis as the patient you are dealing with, you did not come from the exact same background nor have you lived the exact same life as that patient, so you do not know exactly how they feel. And feelings are fickle, how you feel today can be completely different than how you feel tomorrow. One thing I experienced during my sickness was that my emotions were wide ranging. Some days I felt strong and blessed while on other days I felt weak and overlooked.

4. Realize that you are not the only biller calling them.

When you have an extended illness or a condition requiring numerous tests, procedures, surgeries, and visits, the bills quickly add up. All billers know that deductibles and out-of-pocket limits have skyrocketed. A few years ago, the average out-of-pocket limit for most insurance plans was $3,000. This year, the average out-of-pocket limit is $9,000. The majority of patients must make monthly payments and that amounts to $750 per month out of their salary. Combine that with lost time from work and there is a very real danger of the patient's savings being depleted or worse.

As billers, we are in a position to offer tremendous help to patients as they try to navigate through the pitfalls of dealing with their insurance company and their medical condition at the same time. Our insensitivity to them can make or break our office's relationship with that patient and eventually other patients as well. 

Articles

Having gone through the medical system as a patient I came away with some insight into the lives of patients that billers usually don't see.

Improving Patient Relations at Your Medical Practice in 2014 

The end of the month is always a bit stressful for billers between trying to make sure all the charges are entered for the month and all the payments are posted before the close of business on the last day of the month. The end of the year is even more stressful because you have the end-of-December stuff and also the end-of-the year loose ends to tie up.

Here are some practical ways to ensure that your billing department finishes out the year strong.

1. Start the first week in December calling on any appeals that have not been cleared up.

2. Check status on claims that were recently filed. Normally I don't check status for three weeks, but in December, I check claim status at one week to ensure that the claim made it through. If claims are not at least in the system after one week, see if the insurance company will let you fax the claim in, especially for high-dollar claims.

3. Pay extra close attention to benefits. Don't assume that this late in the year everyone has met their deductible. I have several patients whose deductibles started in June. Some plans we've recently encountered require that an office visit copay be paid even if the deductible and out-of-pocket limits are met and don't count the deductible toward the out-of-pocket limit. Not paying attention or not asking the right questions can cause unnecessary amounts left in your A/R at the end of the year.

4. Print a list of your patients with balances due. Consider giving those patients with large balances a percentage discount for payment in full by the end of the year. After all, if you end up turning them over to a collection agency, you will pay a percentage to the collection agency.

5. Gear up for New Year insurance changes. Contact your largest employer groups to see if they will be making insurance carrier changes for the coming year. Contact insurance companies with whom you are contracted to make sure you have the most up-to-date fee schedule. Then make sure that it is loaded into your practice management system. Educate your front desk staff about any changes for the coming year. Remind them that the majority of plans will restart deductibles January 1.

Why the end of the year is stressful for medical billers at physician practices, and what they can do to alleviate some of that stress. 

Five Ways Medical Billers Can End the Year Strong

With so much upheaval going on in the medical billing world right now, it can look like a bad time to be a biller. I know many who have either left the job or are actively making preparations to leave the job. Most are not sad to be doing so. But with all that is wrong, there are still positive aspects to the job. Here are a few of my favorite things.

 The two most important jobs in a medical practice belong to the physician and the biller. Without the physician providing the service and the biller collecting the payment for it, the doors would eventually close. We can hold our heads high knowing that we are helping to provide services to those in need.

2. We help patients navigate the frustrating insurance world. 

All billers know some insurance companies use every tactic possible to get out of paying claims. Patients can be at a loss for how to deal with denials of much-needed services. Plus, the insurance jargon can be confusing to patients who don't work in the field. I take pride in the fact that I am able to help patients with insurance problems.

 This goes hand in hand with number 1. Much of the money we work hard to collect is used to pay salaries. Think of the families you are actually helping when you do your job well.

4. We get to see the fruits of our labor.

 The success of our work is easily defined - either the claim was paid or it wasn't. For me, being able to mark claims off my accounts receivable list is a very rewarding thing. I know how much I have accomplished or where I need to next concentrate my efforts.

5. We have the opportunity to bring about positive change.

 In the billing department, we see how many things affect the receipt of payments. If we see errors that are preventing payment, we can work to have those corrected, thus improving the financial side of the practice. We can work with management to ensure that compliance is met with new rules coming out, which seems to be on an almost daily basis these days.

Every time I am on the phone with an insurance company rep who is treading on the last thread of my patience, I remind myself that I am doing a very important job. I think about the cancer patients for whom I have secured prior authorizations for their surgeries. I think about the people whose questions I've been able to answer, bringing a measure of understanding to them that they were not able to receive elsewhere. I think about the elderly patients who are on fixed incomes and can't afford to pay bills just because nobody helped them fight the insurance company to pay what should have been paid. Sometimes in this job, I feel like the lone ranger, that I'm in this all alone. But, there are many others out there fighting the good fight with me every day.

To all the billers out there who are still plugging away every day, I salute you!

With so much upheaval going on, it can look like a bad time to be a medical biller. Why this isn't always the case. 

Five Things I Love About Being a Medical Biller

Dear Diary, even though it’s Monday, today started out with much promise of being a good day. The end of month collection percentage totals for last month looked great. The percentage of money in the over-120-day-and-aging bucket was down to 0.2 percent and the overall amount due on the accounts receivable report was down by $32,000. I had high hopes that the day would end as well as it began.

My first task of the day was to review the schedule to see which of today’s patients had a past due balance. Finding four such patients, I began to review their history and send necessary alerts to the receptionist. The first two patients had balances from surgeries and were making regular monthly payments as promised. So far so good. The third patient had owed a balance for almost two months and had not yet set up a payment plan, even though he had been back for a recheck appointment just last week. That’s where my hopes for the day began to sag a bit.

The fourth patient had been the victim of a car accident and one of our doctors had been called from the emergency room to do surgery. The hospital had not given us any insurance information on this patient, so I looked to see what information the patient had given at his first recheck appointment in our office. Nothing was written in the section for insurance. Great. As I read through the note history, I found a note from the receptionist that said, "At checkout, asked patient to pay on surgery balance. Patient responded that the accident was the other guy’s fault and that’s who would have to pay the bill." Further notes revealed his adamancy that he was not going to pay this surgery balance. We were at an impasse because our doctor was on main ER call that day and we were required to continue seeing him until treatment was complete. At this point, my hopes for the day were swinging mighty low.

I called the car insurance claims adjustor only to be told that the hospital bills had exhausted the MedPay limits on the patient’s automobile policy and the at-fault driver did not have car insurance. The patient’s attorney had already been in contact with them about a settlement but in all reality, it would probably end up going to court. The adjustor said that if a settlement was reached, it would be paid to the patient who would be responsible for using it to pay the remainder of his medical bills.

I added my note to the history and inserted a pop-up note that I needed to speak with the patient when he arrived. Judging by the previous encounter our staff had with him, I was not looking forward to his arrival at 10:30.

The next order of business on the “to do list” was to check status of pre-certs that had been requested last week. I called ABC insurance company first because three of the precertifications were theirs. I don’t know how so much changes in one week at insurance company, but apparently it can. I dialed the same number I had called the week prior to begin the precert process. After going through the maze of prompts, a person answered who informed me that I had reached the wrong department. I assured her I had chosen all prompts carefully. She asked for the number I had dialed originally. I told her 800-000-0000. She said that was the problem; that number was not for precerts at all. She agreed to transfer me to the correct department. The person in that department would have loved to help me, but they don’t handle precerts for that employer group. Again, I was transferred to the correct department. Four transfers later, I finally connected with a representative who said that if I had just dialed 800-000-0000 I would have reached her directly and avoided all of this unnecessary frustration. I’m glad she couldn’t see my expression through the phone.

Confident that I had at last reached the right person, I gave her the patients' information for whom I had requested precertifications. Two were in process she said, but the third request was not on file.

"Why not?" I demanded to know. I had sent all three sets of clinical information and photographs in the same envelope. If two were there, what happened to the third one, I wanted to know. The rep suggested that maybe I had forgotten to include the third one. I knew I had put all three in there. After 20 minutes of back and forth and being put on hold so she could check with other departments, she finally came back to the line to let me know it was found in the mail room. She informed me that I would have to send the photographs again because she was not able to locate them.

At this point, I gave up all hope for the day ending on a good note and I was pretty sure this was a good indication of how my week was going to be. It was also at this point that I wondered if other billers really faced the same frustrations as me. I also contemplated whether or not billers should automatically have a prescription of Prozac. Like some people have a jar of peppermints on their desk, maybe billers need a little jar of happy pills.

Little things can add up, as this glimpse into a day in the life of a medical biller reveals. 

How Late Payments, Patients can Throw off a Medical Biller's Day

Medical billing is not a job for the faint of heart. There are days that severely push the boundaries of your patience and make you wonder how some people can sleep at night after acting the way they’ve acted during the day. Let me tell you about a recent day that came very close to reaching the limit of this biller’s patience.

The day started out calmly enough; my doctor was scheduled to be in surgery all day and very few patients were scheduled for follow-ups with the nurse, so I had planned on using the day to check claim status from my accounts receivable report. I always start with the oldest claims first so I pulled up my 120-day report and found only three claims. Thinking a little too positively, I prepared for my first call.

The first claim was a breast-reconstruction surgery. I checked the history and found that I had obtained pre-certification prior to surgery, eligibility was confirmed the day of surgery, and the codes pre-certed were the codes billed. The clearinghouse had received the acceptance report from the insurance company from my original billing and from my rebilling. I had to rebill it three weeks later because the insurance company claimed they did not receive the claim. I had been assured since then that the claim was received and in process. Last month, I received a request for additional medical records in order to complete processing of the claim. During my call two weeks ago, the receipt of the records was confirmed and again I had been assured the claim was in process. Payment had still not been received and the insurance website showed the claim as pending.

I dialed the number and made my way through the maze of automated options. For once I wish the automated options were truthful. You know, they really mean: Press one if you speak English (but want your call to be answered by someone who does not); press two if you want to speak to someone (who is going to take their bad day out on you); press three if you want to be transferred (to the wrong department and spend 30 minutes trying to get to the right one); and press four for a representative (who is one denied claim away from their next bonus). And finally: Press five if you would like to be on hold for a really long time. Finally reaching a representative, I stated the reason for my call.

"This claim was denied because you did not obtain a pre-certification," the representative said.

I replied, "I did obtain prior approval and this is the approval number, ABC123. The letter is dated June 17

"We don’t have any employed here by the name Jane Doe. Are you sure the letter is from our company?" the rep questioned me.

"Yes, it has your logo and company name at the top and Jane’s signature is right above her printed name and title, 'Prior Authorization Department Specialist,'" I said.

"I don’t know what else to tell you, we don’t have a Jane Doe here and there is not authorization on file for this patient," the rep stated.

I asked for her fax number or e-mail address so that I could send her this letter as proof, to which she replied that they were not allowed to give out that information. My request to speak to a manager was met with the excuse that there was no manager available. Then I requested to be transferred to the prior authorization department.

After being on hold for 15 minutes, someone came on the line and greeted me with the following greeting, "Prior authorization department, Jane Doe, how may I help you?"

Really?!?!? I wanted to scream. I explained my dilemma to Ms. Doe who did in fact remember issue the approval for this surgery. Her answer was for me to just call the claims department back and tell them she said it was approved. I told her that wasn’t going to help, and that she needed to contact them for me. She expressed her seemingly sincere apologies but regretted to inform me that she could not call that department because she could not make outgoing calls.

Being dangerously close to my patience threshold, I took a deep breath and chose my words carefully. I told her that I had complied with the prior authorization protocol and had in my hand the letter signed by her giving approval for the surgery and that if this problem was not rectified within the hour that I would be sending all of my documentation to the employer, the patient, and the insurance commissioner of Georgia.

That apparently got her attention because she asked me to hold and there was a provider services liaison manager on the line within minutes. After a few questions, this manager assured me that the problem would be resolved immediately. She gave me her name and phone number, promising to call me back before the end of the day with the resolution. I hung up with a glimmer of hope but pretty sure I shouldn’t hold my breath waiting on her return call.

By the time that call was finished, I didn’t have the emotional fortitude to make another call and figured it would be best to take a break lest I take my frustrations out on the next person who walked through my door.

A lesson in staying calm when your day as a medical biller is nothing but frustrating. 

When a Medical Biller Reaches the Limits of Patience

Today is a day of mixed emotions for many people across America, what with it the being the quote/unquote first official day of Obamacare and the government shutdown hanging overhead.

The staunch proponents of Obamacare are joyously dancing in the streets amid a tickertape parade while those who vehemently oppose its inception are hunkered down in a fury of nail-biting anger. I think the vast majority of the population though are in a fog of miscommunication, false hope, and maybe some unnecessary worry.

What does Obamacare really mean to someone like me, an “in the trenches” medical biller? First of all it means that people will be looking to me to answer questions about their insurance now that Obamacare is here. But I have as many questions as they do. The one thing Obamacare has done is put everyone in the same boat, a boat called limbo. We don’t really know how it’s all going to work.

For example, I want to know how reliable eligibility verifications will be. I have claims on my desk right now for which I am fighting retro-termination denials. The day services were rendered, coverage was verified. When the claim was processed, the insurance denied saying the coverage was retro-terminated because the employer didn’t send in notification that the employee had been laid off. In the past, I’ve had denials because the insurance company said the Cobra premiums were not paid. The patient had cancelled checks showing that they did pay the premiums. That fight took me six months to finally receive payment for those outstanding claims. I feel justified in my level of concern for eligibility verification for these government-regulated exchange insurance plans.

Another area of concern for me is precertification. Considering the difficulty regular insurance companies exhibit on occasion, I can’t help but wonder how the governmental connection will affect the precertification process. Just last week, I spent four hours on the phone getting shuffled back and forth between the pre-certification and claims departments of a certain major insurer. The precertification department had told me prior to surgery that no precert was required. I documented the name, date, and time related to this call. Last week the surgery claim was denied because there was no pre-certification. I gave the claims department my documented information and was told that didn’t matter to them because in their system it said precert was required. They said they couldn’t help that the precert department had given me wrong information. I asked if they could get the precert department on the line with us so we could resolve this issue. The response was, “No, we don’t make outgoing calls to other departments.”

So I called the precert department back. They said they were correct, no precert was required and that I should just tell the claims department to pay the claim. I asked if they would please call the claims department for me to verify. That request was met with a prompt, “Once the service is rendered, we are out of the picture.”

Ultimately the issue was resolved, but only because I finally found someone who actually cared about solving the problem and didn’t just pass the buck. I look at instances like this which occur with more regularity that I am comfortable with and I can’t help but think it will there will be worse headaches than this with plans that are overseen by governmental agencies. Maybe we billers should stock up now on aspirin.

My take on the whole Obamacare plan is that making healthcare affordable is a great thing. And if that’s what the Obamacare plan was really doing, I would be more supportive of it. But I think it will do more harm than good. I can very easily see that small businesses will convert employees to part-time status to avoid the penalty. What will that do to families already finding it nearly impossible to stay afloat financially?

I have strong reservations about the government forcing anyone to get health insurance. So many people think that Obamacare is offering free insurance. This is not true. They are forcing you to pay for insurance and the cost of the insurance plans are not readily available. I was just on the healthcare.gov website and I consider myself semi-tech savy. The only way I could find to be able to compare the cost and benefits of the different plans was to actually do your application first. Applying for something before you know the cost is what my dearly departed father would have called "buying a pig in a poke."

It has been my experience in life that people who are trying to manipulate a situation for their own benefit will create a diversion to get your attention off the truth of what they are doing. I think Obamacare has created a diversion with false concern for the health and well-being of the Amercian people. What is its real agenda? It could be simply to rake in more money for the government or it could be something much more sinister. Whatever the case may be, the next several months are going to be very interesting to say the least.

The one thing Obamacare has done is put everyone in the same boat, a boat called limbo. We don’t really know how it’s all going to work. 