Medical billing process - Insurance Calling

Calling process - Insurance calls


The call center (In India) function in co-ordination with the analyst is the most important function in billing. They are the persons who actually speak with the other parties in billing viz. like the insurance and the patient.

In an ideal situation if all required & accurate information is obtained from the patient by the hospital and from the hospital by the billing office in time, this function may not have much importance. But in reality it may not be so. There may be quite a few cases where the information obtained from the patient is inadequate or even incorrect. Sometime there may be cases where the hospital may not maintain proper documentation. All these may amount to claims not being paid. Hence in order to get this information from the patient or hospital and in order to find out from the insurance as why the claims are not paid, this function assumes importance.

We have a call center team who uses a toll-free line to discharge this function. They are provided with a certain script for calling and they raise questions based on this script. The analyst’s work-order would be seen in the screen ‘review notes’. The following day, the analyst would review the outcome of the calls made and take appropriate action on the claims. If they need further clarification, it goes back to the caller for calling again.

The analyst and the caller should be aware of call facilities of each insurance company. They should keep a record of a list of phone #s, time of availability, contact persons, fax #s, AVR (Automatic Voice Response) numbers of each insurance company wherever available.

Certain insurance companies have AVR or ARU (Automatic Response Unit) facilities wherein you can get the claim status information through this. Here you should give the following information after dialing the AVR number:
The patient/ member’s id #
The provider number
The date of service
These should be given in the proper format as per instructions given in the AVR. Once this is done, the AVR gives the following information:
*claim has been paid for $… on ……
*claim has been denied on …..
If you need more information, you will have to talk to the rep through the insurance company claim status phone #.

Certain insurance companies have FAX facilities wherein you can call the carrier for claim status and if you find that the claim is not in their system, you can fax the claim to them immediately. This process will speed up the claims processing and ensure faster inflow of money. The caller should notify the analyst of the request by the rep to fax the claim. The analyst should generate and print the claim and provide it to the caller for faxing. The analyst should have a list of insurance companies, which accept claims by fax and utilize the facility to enable speedy processing of claims.

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