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CPR White Paper: Identifying Payment/Non-Payment Trends of Insurances


One of the main ways that an effective Third Party Billing Company is able to differentiate itself is the ability to identify trends in insurance processing of claims earlier rather than later.  This helps both the Biller and the client to be able to adjust earlier to changes in LCDs for governmental claims and whims of commercial insurances. And therefore keep the cash flow steady.

There are two ways to do follow-up work:

  1. Hand posting paper payments/denials and,
  2. Electronically posting 835s. 

Note: The second way is much more efficient and gives more time to do analysis.

The easiest way to do analysis for trends is to use your practice management system to its fullest.  You need to know what your denial codes are that effect payment.  Some examples include the dreaded “medical necessity denial, lack of pre-authorization denials, your provider is dis-enrolled in the insurance.  We often see denials that appear to be misapplied to save the insurance companies money, banking on people to accept the denials without questioning them in order for the denials to process properly.  Most practice management systems do give you the ability to separate the “CART” codes (denial codes) and work the denials by type of denial and insurance.  This process makes it very easy to spot when an insurance company has a glitch in its system, or someone is making mistakes in the processing.  After you identify the trend, talk with the insurance company giving examples so they are able to quickly fix the “problem.” If your PM system is not able to help you to do this with relative ease, we suggest finding a more useful PM system for your company.

Some “tricks” that we have found in doing follow-up is that insurance changes the allowable Dx’s for a procedure to be reimbursable, but don’t seem to find it necessary to let the provider know in advance.  When you do find this type of change, hopefully your system can have an edit in it to make sure that Dx code is not used and your staff can find in the documentation a more useful code.

Industry standards also strongly suggest that you or your clients verify eligibility electronically.  If you are unable do this before the patient is seen, try and do it prior to sending in your claim(s). Lack of good eligibility information has become even more important since the advent of the ACA, and patient’s ability to move between coverages relatively easily.  There are programs and vendors who can help with this.

You can also, if your client is not Par with an insurance company, stop all your 835s. have an employee who is familiar with this process post the payments and find out if you are accepting adjustments that you shouldn’t be accepting.

The take away is to learn to use your staff and your system more effectively.  This is how we as third party vendors make sure we are doing our job properly and differentiating ourselves from the competition.


This paper was authored by Commercial Payor Relations Committee Member Sue Irwin, MCS-P, 
Medical Billing Authority, Avon, OH.