PREVENT BAD DEBT - MANAGEMENT EDI CONTROLS AND FOLLOW UP

Electronic claiming and account reconciliation should be a simple process, yet many practices fail to follow the crucial administrative processes that should be the backbone of any debtor management office or department.

Electronic claiming and reconciliation within your PMA product is surely the easiest way to manage debtors, but can and may never replace basic, sound human intervention and routines, to ensure effective financial control.

It is always good to ensure that the basic controls are in place thus ensuring that your income is never compromised by an ancillary system or product. This ensures that your income remains in the hands of the financial controller that is responsible for debtor control.

In an ideal practice set up, claims should be sent electronically and processed in real time, allowing for real time delivery and receipting thereof. In most cases where real time processing takes place, you will be able to get an instant response as to whether a claim had been processed and approved while the patient is still in front of you.

This is the most effective financial control available to ensure instant approval confirmation and also prevents the age-old issue of non-payment by either patient or scheme.

Your proof that the medical aid received the claim

Where a scheme does not have real time processing power within their systems and are only able to receive batch claims, it is still best practice to send it immediately and await receipt / confirmation that the claim had been received by the scheme and is not stuck in transit somewhere between the PMA, switch, and the scheme. 

In all instances a receipt is paramount in this initial phase. Without an actual batch number it is very difficult to track down an unpaid claim. All the switching houses provide a further internal medical fund reference number as proof that the medical aid has in fact received the claim through their switch.   

Confirmation is not foolproof unless you have access to the medical fund reference (batch) number (proof that they accepted it). Depending on which switching house you use the reference will be noted in your PMA or on the switch’s website, or both. Basic confirmation from your PMA that the claim had been sent should never just be accepted as being the Alpha and Omega of claims delivery. 

From time-to-time medical schemes simply do not pay the claim sent through. This is due to either glitches or technical errors in the tools used to facilitate debtor management or claiming, leaving claims unpaid on the system. In the feedback reports one should look out for the following: the number of claims sent, the number of lines included in this ‘’batch’’ and the total Rand value included in the “batch’’.

In case of rejection you will receive a rejection report indicating any errors within each ‘’batch’’. These claims will need to be corrected and resent to ensure that they are paid.

In instances where claims are processed in real time you can also receive an electronic remittance advice that can be electronically reconciled against the claims sent. Once again this electronic process needs to be checked to ensure monies are correctly allocated, unpaid claims remain within the ‘to do’ environment and to also follow up on any uncertainties or partially paid claims.

Patient/ member responsibility

One basic control mechanism to ensure that your claims are paid is to remember you are obliged to send a duplicate statement to your patients – this rule still remains in place and is required by the medical schemes. At the end of the day no patient can shift the blame away from themselves since it remains their responsibility to honour your account and pay for the services that you have rendered.

Maximising payment on rejected/unpaid claims

Your financial controller/ debtor clerk must react immediately when a claim is rejected or a claim that remains unpaid at month end and must be followed up meticulously – this responsibility can not be shifted to anyone or anything and remains the most important cog in the wheel to facilitate speedy payments.

There are three common reasons for sending claims for a second time.

• Incorrect claims that have to be corrected and resubmitted immediately. If the switch made the rejection the new send will go through instantly.  (Correct/accepted claims may not be resubmitted immediately as they will be picked up as a duplicate and then rejected)
• Some switches allow you to now resubmit an unpaid claim after 21 days if the medical aid has not yet paid. However if it is in the process of being paid by the scheme it is likely they would reject the claim as a duplicate.
• Lastly if the medical aid notifies you that the information they received is incorrect then you may amend the claim and resend it. The different switching houses require different processes for this. The financial controller must be aware of the appropriate method.

Unpaid statements should be printed and followed up by your financial controllers – it is critical that unpaid accounts are never left unattended…

TIP1:  Your PMA produces reports on claims, which still have a rejected status. I suggest that at least once a month you request a report of all claims with this status to prevent problems further down the line.

TIP 2: In the worst case, unpaid claims older than 60 days must be sent under a cover letter, demanding attention,(this in fact also applies to non electronic claims) or explaining reasons why the specific claim is still within the system and outstanding. If all of these attempts to facilitate payment fail, a telephone call seems to be the next step. Please ensure that you have all references at hand as that will ensure quick and accurate tracing of all outstanding claims. i.e. your batch number and the medical aid reference/batch number.

In all cases where claims are left unattended and financial controls are not in place thereby letting the claim reach 90 days, these claims will become stale and will not be paid by the scheme. It sometimes happens that a specific process becomes corrupted or a glitch prevents a claim in being able to reach its destination and Medical aids may be unsympathetic, if the follow up by the practice was not made sooner.

TIP 3: Check how much of your book debt is unpaid member portions.  If the medical aid has stated that they will not pay, the normal credit control procedures should be implemented immediately. These include either phoning the patient, printing a copy of the account or sending the patient a letter. The sooner this is done the more control you have. Make sure that these types of rejections are in fact being transferred to the member liable column in your PMA so that your medical aid book debt is not distorted.