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34: Claim Denials in Speech Therapy Private Practice

When you work with insurances in speech therapy private practice, you will have claim denials. In this episode, I discuss common causes of claim denials as well as speak about patterns and trends to watch out for when dealing with insurances so that you can get paid.

In this episode:
01:28 – Happy Mardi Gras 2018!
04:40 – Claim denials in Speech Therapy Private Practice
05:10 – Explanation of Benefits (EOBs)
05:44 – Benefit Checks
06:35 – Documentation and Proof of Insurance Verification
07:05 – Noting Plan Customer Service Representative details
08:16 – Timely Filing rules in Speech Therapy Private Practice
09:16 – Patterns and Trends to note when looking at reimbursements

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Also when you look at claim denials for Speech therapy, was it a data entry problem? Did you put their correct data service? What about the patient’s date of birth? Was that correct? Or the subscriber number, was that entered correctly? Every card when you look at the front and back of the insurance card, you’ll see a subscriber number. Also was there an authorization number that should have been put on there? And you want to make sure that there’s no data entry problems on the claim.

[Commercial]

Well, Hello everyone! You’re listening to the Speech therapy Private practice Startup Podcast; this is episode number 34. My name is Kyle Meades and I’m a speech and language pathologist since 1993 and these podcasts are designed to help you improve your business and your life one podcast at a time.

Welcome back to the show everyone. Today is February 11, 2018 and as of today we have well over twenty eight thousand seven hundred and twenty five listeners to the show. Some of which I know for a fact from the New Orleans, Baton Rouge, Southeast Louisiana area and Happy Mardi Gras to you guys down in Southeast Louisiana. Hope you guys are having a good time because every time, this time of the year rolls around I get real homesick. Here in the Tucson, Arizona sunny dry and a missing night gumbo, fried shrimp, oysters, red beans, rice and sausage. It’s crazy.

The other day, yesterday at the office she says, “Hey Kyle, what’s a king cake?” I say, “Well that’s something we eat in New Orleans around this time every year in New Orleans. It’s a pastry is kind of like a bagel cinnamon roll and it’s in a circle form and it’s got sugar on top of it. The sugars colored green and gold and purple those Mardi Gras colors and there’s a little plastic baby in there and everybody gets slice and whoever gets the plastic baby has to buy the next King cake for the next party. Now everybody is like well, “Don’t swallow the baby, you can’t. No, you don’t swallow the baby. You spit it out and show it to your friends and say I got the baby I gotta get the next King cake.” And where do you get a King cake?” I say, “the best place to get a King cake is either Gambino’s bakery or Haydel’s bakery on the West Bank. They got the moist King cake. You want it to dry has got to be moist. Anyway this is some second line music from the city of New Orleans and if you hear this. Anywhere in the area of New Orleans southeast Louisiana it means you’re close to the Mardi Gras parade route. So this is it.

I used to live on 716 Dauphine, New Orleans in the French Quarter and my balcony wrapped around and looked down Dauphine street down towards Downtown. And then you kind of wrapped around Orleans and you look towards Bourbon Street and the sights that you used to see from that balcony I could write a book. Good clean family fun from that balcony I tell you what. Have you guys ever been in New Orleans? That’s a fun place glad to live in Tucson right specially my late 40s. I’m just turned 48 this past Christmas Eve and starting to fill it in my hips and my knees. So not like I used to be but anyway Happy Mardi Gras all you guys.

When you look at the statistics over on the podcast you’ll see around the world. You’ll see that obviously the United States is topping the charts but you got Japan and Australia, the UK, Canada; we’ve got listeners in India, Germany, South Africa and also the Republic of Korea. That’s interesting. And also when you look at the United States as a whole, we’ve got California still topping the charts. It’s always back and forth between California and Texas. Then we’ve got New York, Florida, Arizona, Illinois, New Jersey, Pennsylvania and Maryland. So again wherever you are but especially this week Happy Mardi Gras to you guys out there in New Orleans in the Southeast Louisiana region and for all you Speech pathologist out there listening “Y’All is singular and all Y’All is plural” so all y’all have a real good Mardi Gras and I’m glad you’re tuned into the show. Please if you wouldn’t mind go to the platform of your choice. The Android platform or the iTunes platform and leave some good five star feedback. That way other people can get the same valuable information that you’re getting.

So today I’d like to talk about “Claim denials in Speech therapy”. Now why is that claim denied. Any time you deal with insurance companies or Medicaid or Medicare, when you’re working with insurance companies or other payers, other than in cash and credit card and checks, you may get what’s called a ‘Denied claim’. Now when you look at that deny claim you’re going to get what’s called an E.O.B. That may come in the mail but if you’re savvy, if you’re doing it electronically you’ll look at it immediately when that claim is denied. You look at the E.O.B, that stands for ‘Explanation of benefits’ and sometimes it will tell you, well it wasn’t really denied that the cost of care went to the patient in the form of deductibles or copays or coinsurance.

Also if you look at the E.O.B. it might say the patient termed their insurance for that date of service. So again if that’s happening especially if the patient termed when you saw them that means you didn’t check the insurance before you saw them for that therapy visit. So again anytime you see a patient you want to have a system in place so you can check benefits to make sure that in actuality the health insurance that the patient has, make sure it’s Active. So we do discuss these types of things in the All Access Community the online forum that I have in privateslp.com/coaching, if that interest you please go there and I’ll help you with your coaching, billing and collection needs. Also when you look at claim denials for Speech therapy, was it a data entry problem? Did you put their correct data service? What about the patient’s date of birth? Was that correct? Or the subscriber number, was that entered correctly? Every card when you look at the front and back of the insurance card, you’ll see a subscriber number. Also was there an authorization number that should have been put on there? And you want to make sure that there’s no data entry problems on the claim.

A third thing, when you put the data on there and you compile your data you want to make sure that you have screenshots for the data service when performing eligibility checks. So in other words, if you’re doing this electronically if a patient comes in for their appointment and you confirm that the patient does have insurance at the time of service. You want to take a screenshot of that and file that in the patient’s Online folder. That way you’ll have that as proof if there is a claim denial.

Any time you talk to a representative you want to note the time and date in the name of the customer representative that you spoke to. Sometimes they have a number they’ll give you that and you just be very polite and say, “What is your customer I.D. number and they’ll give that to you”. So when you’re dealing with pre-authorization or Insurance’s you want to note the time and date and the person to whom you spoke. Also when you deal with claims in Speech therapy you may have to attach notes or evaluation reports, always include the medical prescription from the doctor. That’s really important. Some insurances have exclusions under limitations so even if you have a medical disorder in the notes sometimes those works sometimes those don’t.

So again we’ve received letters in our clinic for patients who obviously need the care but the insurance they’ll say something like “We’re not doubting that this patient does need this service. We’re not saying that it’s just this isn’t a covered benefit under this person’s health plan.” So again it may be in medically necessary but some insurance companies don’t pay for Speech therapy. So again when you price your services in your area make sure you price it accordingly and appropriately so these families can get what they need from you.

Also there’s deadlines timely filing rules. So those vary from six months to a year sometimes three months 90 days. So by the time you see that person in your clinic you want to submit that claim. You can’t sit around and hold these claims for two or three months. You can’t, you may run into problems and by the time there is a problem if you have a denied claim then you don’t have time to go back and correct it. So you want to make sure that you are billing your services out the day so you don’t get behind and you get paid because when patients come to your window when they come to your clinic, they can’t be any financial ambiguity you need to be very clear this is what you owe. Today I spoke to Marcy at United Healthcare. She said you have a 30 dollar deductible and you need to pay that today. You build a claim out and then you’ll get your portion few days later in the mail in the form of a check or if you’re set up with UnitedHealthcare automatic deposit you will get that into your bank account. So that’s something to keep in mind deadlines.

And also you want to look at Patterns and Trends. This is a very important thing as a business owner you’ve got to look and see do we have any denied claims from let’s say one third party liability or do you see some of your Medicaid plans are not providing prior authorizations for your kids that you see or your patients that you’re treating. And it’s up to you as a business owner. This is very important if you start seeing patterns and trends like denials for medical necessity clause basically this claim is not going to be paid because it’s not medically necessary or if the health plan is making you do these crazy things like you’ve got a valid prescription from the doctor, you’ve got an authorization for an evaluation. You do that evaluation then the health plan says we need to send that kid back to his pediatrician to get another referral. No, if you see those patterns and trends you need to call and talk to someone at the health plan that might be a nurse or it might be somebody in charge and if you have to go to the state level, go to the state level and you want to be that person who stands up for not only your business but your patients.

Your patients need these care and they’re relying on you to be an advocate for them. So again don’t be afraid. We just recently went to the state of Arizona, talked to the attorney general’s office. We talked to the head of the Medicaid department. We’re really working hard to make sure these children get the services that they need. Again it’s up to me as a business owner to make sure that my patients, my staff, everybody gets what they need.

So again you have to be an advocate for your business so always look for patterns and trends with payment, collections and denials, so always keep a notebook or somewhere keep some data on that. So I hope this has been valuable information for you in this podcast and if you need any help, reach out to me kyle@privateslp.com or privateslp.com/contact and thank you for listening.

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