Diligence and documentation are the keys in receiving payment for a claim that somehow moves sideways. We recently had an ablation from October, 2014 that went sideways with Harvard Pilgrim.
The claim was submitted in a timely fashion. This is documented from both the Practice Management system and from Harvard Pilgrim since they sent us a denial in a timely fashion. The stated reason for the denial was ‘No Authorization’.
Authorization had indeed been obtained. Multiple calls were made to the Harvard Pilgrim noting that we had an authorization number. The various representatives stated they would send the claim back for reprocessing. The key here is that the documentation in the Practice Management system noted not only the conversations but also with whom we spoke and the reference number for the telephone calls.
Apparently the claim was never sent back for reprocessing. After further attempts we were informed that we needed to appeal the claim. Multiple calls were yet again placed to speak with a supervisor. Again, each of the calls noted with whom we spoke, the conversation, and the reference number was documented in the system. We finally acquiesced and submitted an appeal.
Shockingly enough, Harvard Pilgrim denied our appeal, which they mandated, for timeliness. At this point we are pretty miffed and again called asking to speak with a supervisor. We were told that we can never reach a supervisor directly but one would call us back. This, of course, never happened. All calls were again documented along with the reference numbers.
Our final call to Harvard Pilgrim, a year later, was another attempt to reach a supervisor to resolve this claim. We were again not called back. We did tell the representative that we would be now contacting the Division of Insurance for that state. A packet of information was put together and mailed to the Division of Insurance, the CEO of Harvard Pilgrim, the claims department of Harvard Pilgrim, and a copy to the patient. The documentation not only included the claim but the pages of notes including all of the reference numbers for the various telephone inquiries as well as all supporting documentation including the original authorization and the denial letter from Harvard Pilgrim.
A week and a half later we received a telephone call from Harvard Pilgrim’s management team apologizing and noting that the claim would be paid within eight business days.
In short, keeping excellent documentation of your telephone calls including the reference numbers along with diligence and persistence can resolve claims even a year later.
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