WCH Billing Service – your shield against revenue losses

In December, our Billing Department experts resolved two major underpayment cases resulting in significant losses of reimbursement experienced by our clients. Please keep reading to find out how to prevent underpayments and excessive charges from happening. The story is told from the perspective of Julie Markova and Nozima Kholmukhamedova, the account representatives working on these two cases.

 Well, 2021 was a challenging year for our Billing Department. Many insurance companies followed the path of the CMS and introduced many new insurance claims edits. As a result, our clients had been receiving dozens and dozens of denials, underpayments, and recoupment requests for the services that had been medically necessary and billed appropriately. It is only in 2021 that we started working together on the same client accounts. In a single year, we had reprocessed hundreds of insurance claims. Some of them had been incorrectly denied as non-covered services, while most of them had been underpaid due to non-compliance with the very same CMS reimbursement policies. Such denials are quite trivial and easy to deal with.

  However, there are two significant issues that are different from any other cases that we had previously encountered. We are proud to have resolved them in 2021, and here is some advice that we would like to share with healthcare providers to follow in 2022:

I. Check your payment rates before you notice a 6-figure amount missing in your bank statement

One of our clients regularly bills Transcranial Magnetic Stimulation (TMS) therapy services to a major commercial insurance active throughout our country. Several months ago, we noticed that the payer had been applying an incorrect payment rate to each processed procedure code. Namely, the payer had been using a reimbursement rate that was different from the one mentioned in our client’s enrollment contract. We did some calculations and discovered that there was an underpayment worth thousands of dollars! After months of endless calls and appeals to the insurance, we had been able to reprocess every single underpaid claim by December. Every single penny has now been repaid to the client. Moreover, we took all the necessary steps with the insurance credentialing department to prevent such issues.

II. Be attentive to your recoupment requests

Back in February, one of our clients, an outpatient hospital provider, was paid twice in error by another major insurance company. Shortly after an overpayment had occurred, the payer issued a recoupment letter to our client, requesting back the amount that was paid in error. Since it was a valid refund request, we advised this provider to send a paper check to the insurance instantly. It was done immediately, and we closed this case. However, in April, we noticed that the provider had stopped receiving any funds from this payer. Indeed, apparently, all the new payments had been applied to our client’s negative balance with this payer. Why would there be a negative balance when a recoupment amount has already been refunded? Upon further investigation with the payer’s customer service and accounting department, we were able to verify that the payer had recouped the needed amount twice: first by receiving a paper check and then by subtracting the same amount from the client’s provider account. We spent the next several months sending piles of appeals to the payer and calling its customer service and billing supervisors. Finally, we closed the case by mid-November. An entire outstanding amount illegally taken from our client’s provider account has been paid back. The client is satisfied, and so are we.

And this is just a single story of accomplishment! Throughout our two decades of experience, WCH Billing and Credentialing Department experts have dealt with thousands of cases like this, helping to resolve major & minor underpayment cases for over 500 practitioners nationwide.