Hello again colleagues,

Just when I thought I might have heard every possible managed care excuse for not paying claims, I was ‘blessed’ today with a brand new story! Here goes: A company for which I have been on the panel for several years summarily decided that a long-term patient of mine no longer exists. Well, I should qualify that, I suppose. They stopped paying my claims 4 or 5 months ago saying that my patient did not exist in their records. Hmmm... I am pretty sure I didn’t imagine her, so I called today and spent in the neighborhood of 3 hours dealing with this. Here is what I figured out:

Said company can only agree a patient exists if the patient id, date of birth, and spelling of last name coincides with THEIR records. Now, it is apparently irrelevant when my data is accurate, but theirs is wrong. When that happens, a patient no longer exists. Hmmm... So, what was happening? Well, they had made a data entry error and changed her birthdate by one day. Instead of being born on the 11th of the month, they said it was the 10th. The year was accurate, the month was accurate, the name spelling was accurate, and the patient i.d. was accurate, but because of THEIR data entry error, the patient no longer existed. Try as they might, the customer service people could not find her if all three pieces of data did not match perfectly. I finally noted their error on an EOB and brought it to their attention. When they plugged in the wrong date of birth, my patient magically appeared like a genie! It was amazing. And no one apologized for the 3 hours of headache and wasted time I spent trying to get them to pay what is less than half of my normal hourly rate.

2 mos. later…I received the EOB for this patient last week, and lo and behold, said managed care company rejected 6 dates of service saying that they were not filed timely enough.  I told them that I have records of them rejecting these claims on three separate occasions previous to my figuring out THEIR data entry problem, and they said that I would now have to send in an appeal, proof that my online billing company had attempted to transmit these claims, and proof that they had rejected them.  They will ‘consider’ the claims and *might* pay them, but now I am allegedly the ‘bad guy’ because the claims ‘were not received in a timely fashion’, never mind that they had rejected them because THEY had the birthdate wrong.  Oh, the story seems to just guess worse.  And that is another reason why I hate managed care.