NHIA Reimbursement Training Center


Collection of services provided is an integral component to any company.  It is your cash flow.  It allows your company to continue operating.

There are several types of collections

    • Government
      • Medicare, MCR Advantage, PPFFS
      • Part D
      • Medicaid – Spend-down, QMB, SLMB
      • Tricare
      • Veterans Administration
    • Commercial
      • BCBS, Anthem
      • Aetna, Humana, UHC
      • CareCentrix
      • Auto Carrier
      • Workers Compensation
      • PBM/Prescription Card
    • Patient Pay – No Insurance Coverage
      • Credit Card
      • Statements
    • Balance after Insurance
      • Statements          
      • Collection Agency

There are several steps of collections

    • Follow Up/Tier One/Initial Collections
    • Subsequent Collections – Claim partially paid or denied
    • S.W.A.T Collections

The process:

Basic Follow Up Collections:

PURPOSE: The purpose of basic follow up collections is usually just to ensure that your claim was received and is in process.  This is a VERY important step if you have sent a paper claim.  While it is desirable to send as much as possible electronically, there are likely still claims that you need to send on paper. 

TIMINGWhile the overall process for home infusion collections has gotten easier in recent years, or more streamlined, due to more standardization of coding, it is essential that you are following up on claims that are sent either on paper or electronically a minimum of every 30 days unless there are specific extenuating circumstances. It is recommended that you confirm receipt of paper claims within 14 days unless a payer takes longer that that for the claims to appear on their system.  If you are not following up in regular intervals, you are putting your claims as risk for timely filing denials which will result in no payment for services rendered! 

STEPS: Either go on-line or call the payer to determine if your claim has been received and is in process.  Note:  If your payer(s) does not have an on-line portal today, inquire in regular intervals as it is likely they eventually will.  You should also search the payer portals for additional functionality on a regular basis.  (Anything that help you get paid or appeal more quickly and efficiently is work the effort!)

    • If your claim is not on file (electronic):
      • Confirm your claim was accepted through the clearinghouse/claims management solution system
        • If no, either resolve the error in the initial transmission and resend or if you cannot locate the initial transmission, resend to the payer and track closely.
        • If yes, validate the electronic payer ID#.  It is likely that your claim appears to have been sent, but it may have been sent to the incorrect payer due to a set up issue.
    • If your claim is not on file (paper):
      • Confirm the estimated period of time it takes for a claim to show up in their system when sent on paper.  If the time frame has passed, resend the claim.
      • Confirm the address to which the claim was mailed.  If the address you have on file is correct, resend the claim.  Note:  Statistics show that one in ten paper claims end up in the circular file (ie:  shredding bin). 
    • If your claim is received and is in process:
      • Determine the normal processing time
      • Ask if the provider can do anything to expedite
      • Ask how often checks are cut (ie: every day, every other Monday, etc.)
    • If your claim is paid:
      • Determine if the check was actually cut and if so determine when it was mailed
      • Determine how long it takes for a check to cut from when the claim is processed
      • Determine if there is a way to set up an electronic fund transfer


Subsequent Collections:

PURPOSE:  The purpose of subsequent collections is to ensure that every claim is paid in full as expected. 

TIMING:  For any claim that is partially paid or denied, follow up should occur as soon as possible.  A recommended limit is no more than 7 days from the date of receipt.

STEPS:  Similar to the basic collections, subsequent collections can be done on-line or over the phone.  However, unlike the basic collections, the majority of subsequent collections is done over the phone.

    • If the claim denies for lack of medical necessity (and you were expecting payment):
      • Validate that you have an ICD-10 code that supports the need for the therapy.
      • Validate that you have the documentation/medical records required to justify the therapy.
      • Once you have confirmed above, call the payer and determine:
        • What is the specific reason(s) the claim denied for medical necessity
        • What is their policy on medical necessity for the service your patient received.
        • What is their appeal process (ie:  on-line, paper, attachments, special form, etc.)
        • Determine if the appeal address is different than the default payer address you have on file or if possible ask if it can be faxed.
        • Inquire about the turnaround time for appeals.
        • Determine if there is a dollar value limitation for appeals.
      • Once you have gathered everything you need, submit an appeal that will result in payment.
    • If the claim denies for insurance coverage terminated:
      • Validate with the payer the date the insurance terminated.
      • Contact the patient and determine their current coverage.
      • Bill the correct payer ASAP. 
    • If the claim denies (one line on a claim or all) for an invalid code or modifier:
      • Validate that the code and or modifier billed is current and applicable
      • Contact the payer to determine what cause the denial.
      • If it is a simple fix, ask if they can send the claim back for processing based on the info provided. 
      • If not a simple fix, determine the process required to correct so that the rebill or appeal will not result in another denial of duplicate claim.
    • If the claim denies for no authorization:
      • Determine if there is an authorization on file.
        • If there is no, review the insurance verification notes and ensure that this was requested during the verification process.
        • If there is an authorization, validate that the number(s) is correct and determine what was authorized.
      • Call the payer and inquire why claim was denied (if you were told you do not need one or if you have one on file)
      • Confirm the appeal process (similar to #1 above)
      • If you did not obtain an authorization, and they are now stating it was required, fight until the bitter end for getting the funds that you are due.
    • If the claim denies for timely filing:
      • Ensure that you have proof of filing
      • Ensure that you have copies of all paper claims sent.
      • Validate the timely filing and/or timely appeal limit.
      • If there is a valid reason for late filing, discuss with the payer
      • Submit an appeal with as much proof as possible that claim/appeal was filed timely to ensure payment in full.
    • If the claim paid less than either:  your contract rate, your cost times X (x is whatever you deem to be your minimum acceptable payment limit):
      • Contact the payer to determine why paid so low.  (If it was a drug, you will have to validate the units billed and confirm if the drug should be billed in HCPS units or NCD vial, etc.)
      • Determine if your payment includes a penalty for late filing, out of network rate, or something else that just applies to your pharmacy.  If so, ask why this was applied and how you can reverse it.
      • Gather all of your facts and submit a timely appeal to the payer for more funds.

There are many other reasons for denials or short pay.

Some additional general collection tips:

    • EVERYTHING must be documented in the AR notes.  The more detailed you can be, the better.  This is the MOST important step in the process.
    • Make sure your notes are time/date stamped.
    • Create note templates by scenario so that all of the collection staff has the same expectations and so they don’t miss any key elements.
    • When doing status calls, try to tackle several claims at the same time for one payer.
    • Don’t ever accept a denial or short payment without a fight. 
    • Always try to find an easier way
      • from paper claims to electronic
      • from mail to fax
      • from submitting appeal to having payer reprocess
      • from paper checks to EFTs
    • Be prepared before you make a call:
      • Have your NPI/TIN/PTAN available
      • Have the patient information such as DOB, Name, ID, subscriber available
      • Have the date of service, billed amount and or previously paid amount ready
      • Know your contract rates
    • Track what has been successful and what has not
    • Don’t settle for a canned answer without probing further. (example:  Your claim is in review.  You should ask:  for how long, why, what can I do to push along.)
    • Be confident in your pursuit of payment in full.  (Don’t be intimidated)
    • Celebrate milestones along the way.
    • Treat your assigned AR as it if were money due to you.  This allows you to think outside of the box and this will ensure your success! 

EOB sample and explanation