When a Medical Biller Reaches the Limits of Patience

October 15, 2013

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

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 17th and signed by Jane Doe."

"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.