Delays and Denials… But Why?

Picture this: It’s January 8, 2014, and you’ve just submitted 27 claims across CPT codes 97001, 97010, 97140, 97530 and G0283 — totaling $5,500 in billables and, ultimately, $2,100 in revenue. The claims are earmarked for Blue Shield of Sarasota, and get submitted through the Emdeon clearinghouse. You wait, and you wait for your reimbursement. Weeks pass, and you decide to follow up by calling Blue Shield. After wasting more than two hours on the phone, you discover that the contract between Blue Shield of California and Emdeon was terminated on January 1, and you never got a notice. Or, just as likely, you got one, but it got lost amid the volume of junk that arrives at your office each day.

This is nothing new. Claims that used to get paid are suddenly delayed or denied… and you have no idea this is going to happen, or why it happens, until it does. And so you’re forced to go through the rigmarole of contacting the payer, in an attempt to get a straight answer. Maybe the payer has an explanation. Maybe not. In fact, there’s a good chance the claims never make it to the payer’s doorstep; instead, the issue originates at the clearinghouse — which presents another set of challenges as you struggle to sort things out and, most importantly, get paid.

This sort of thing happens all the time. Not just in January 2014, and not just with this particular payer and clearinghouse. Such problems happen at least a few times every year, and they can happen in any state, with any payer.

Fortunately, bestPT clients have the benefit of someone who’s on the job 24/7, working to make sure that providers don’t have to deal with this kind of hassle. The Physical Therapy Billing SWAT team is a group of dedicated professionals who are tasked with solving large-scale and complex physical therapy billing problems that fall beyond the expertise of your coach and billing team. Yet their work is something you’re not supposed to notice; providers take comfort in their capability, since when the SWAT team is on the job, important billing matters go according to plan.

The Billing SWAT team is constantly looking for ways to improve the reimbursements you receive. Their expertise includes:

  • Vericle system knowledge;
  • Troubleshooting complex physical therapy billing issues;
  • Rate validations; and
  • Practice management coaching.

In the case of Blue Shield of California and Emdeon, notification was sent to providers, but not to billing companies. Fortunately, the billing SWAT team was able to take the matter in hand. Not only was the team able to recode nearly 2,500 affected claims, but by virtue of the Network Effect among bestPT users, they were able to get word to all providers — thereby avoiding further complications — and, within weeks, had the issue completely resolved.

Remember, when you rely on a service for your day-to-day needs — be it your electricity, your Internet provider or your billing company — it’s very easy to take it for granted; you don’t think much about it until something goes wrong and that service is interrupted. Yet there is a lot going on behind the scenes — work that may not grab attention, but is absolutely crucial for the system to run smoothly.

If at any time you have a billing issue, simply open a ticket to the PT Excellence Center Director or team members. They will then relay the information to the billing SWAT team, who will take a tactical approach to finding a solution.