How To Understand Professional Medical Billing: No Authorization Claim Appeals
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How To Understand Professional Medical Billing: No Authorization Claim Appeals

For medical billing, it matters if the hospital facility is in network.

This information on filing medical billing claims is intended to help medical billing professionals and is not intended for patients or the general public.

Filing a late medical billing claim is like the kiss of death for getting paid as you only have 180 days to file a claim but sometimes the patient does not even give us the insurance company information and then we get the information late and then we get denied for timely filing when we didn’t even have the goods to begin with. Here is what to do in that situation.

In my notes on this case I wrote that the patient called in and said that he gave all of his information about Cigna to the Surgeon’s office and said that we should have filed to his insurance carrier. I told him we which is the anaesthesiologist's office filed when we got the information about the carrier and then the medical claim was denied for timely filing. I said since the claim was denied for timely filing and the patient did not respond to a year’s worth of bills from our office we can bill the patient for the full fee. I tried to get a payment plan of $100.00 a month or the account would be sent to the attorney and he would not agree to that. I got the correct spelling of the patient’s name and address and home telephone number. The patient said that he was not working right now.

In an associate’s notes that she wrote on this case she said that the patient did receive bills for a year, but the bottom line was he choose to ignore them because it was not his job to resolve the situation, at first it was the surgeon’s fault, then it became the anaesthesiologist's fault, but he is not responsible for anything other than a co-pay after insurance. She tried to explain that usually if a facility and surgeon are in-network Cigna may reprocess the claim for the balance and there would not even be a co-pay but he must appeal and resolve this with his insurance carrier if not, he is liable for the anaesthesiologist bill as the anaesthesiologist is not panel with Cigna and the patient chose to ignore a year’s worth of bills and correspondence (patient verified his mailing address.) Patient refused to pick up the telephone and call his insurance company. The end result was that a letter was sent to the attorney to start the collections process.

You can also have the insurance carrier pull the patient’s contract and check to see if the facility is in or out of network. Also have the insurance carrier see if the anaesthesia group on staff is in or out of network.

If the facility is in network and the anaesthesia group is out of network have the insurance carrier reprocess the claim because the facility was in network.

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