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The accounts receivable follow-up team in a healthcare organization is responsible for looking
after denied claims and reopening them to receive maximum reimbursement from the insurance
companies. Medical billing A/R and revenue cycle management handled by an in-house team is a
thing of the past. Today, it demands billing professionals with a specialized skill-set to look after
the A/R follow-ups. The primary goal of the AR is to identify and collect insurance reimbursement
from the third party insurance carriers. After identification, confirmation, and submission of the
claims to carriers, aggressive follow-up is critical to the success of the AR Dept... Often claims are
lost, delayed or misdirected. When that happens, for whatever reason, the insurance carrier will
assume the claim was never submitted and deny payment based on non-receipt of the claim. At
other times, carriers might underpay on submitted claims. For underpaid claims and claims not
received, proper follow-up and perseverance by AR can dramatically improve third party
collections. Effective claims follow-up can even result in payment for claims which would
otherwise be written-off.

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There is a massive amount of work to be done before the physician can claim an amount from the insurance firm. Ideally
an A/R team comprises of two departments -
A/R analytics
A/R follow-up
The A/R analytics team is responsible for studying and analyzing denied claims as well as partial payments. Also, if any
claim is found to have a coding error, the A/R team corrects it and resubmits the claim.
 Caller will call up the insurance and verify if the claim is with the carrier and its current status.
 Caller checks whether the claim is being processed for Payment or denial.
 Based on the inputs from the caller, the analyst goes to work and gets the required information needed.
 Incase of payment, the analyst would compile a list of payments details or if denied then corrective action is initiated.
 The calling team received work orders from the analysts and initiates calls to the insurance companied to establish reasons for
non-payment of the claim.
 All reasons are passed on to the analyst for resolution.
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• Stage 1: Initial This stage involves the identification and analysis of the claims listed on the
Evaluation A/R aging report. The team reviews the provider's policy and identifies
which claims need to be adjusted off.

This phase is initiated once the claims are identified which are marked as
• Stage 2: Analysis
and Prioritizing uncollectible or for claims where the carrier has not paid according to its
contracted rate with the healthcare provider.

The claims identified to be within the filing limit of the carrier are re-filed
after verifying all the necessary billing information such as claims
• Stage 3: Collection processing address and conformation to other medical billing rules. After
completing the posting of payment details for outstanding claims, patient
bills are generated as per the client guidelines and then followed up with
the patients for payments.

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 Missing or Time
Lost Claims Incorrect requirements Simple Errors
Information's for filling

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1. 1. Financial Stability of the Hospital: The financial stability of any healthcare service provider is highly dependent on
maintaining a positive cash flow. The hospital has to maintain a steady flow of revenue to cover expenses so as to provide
patient care services, and the A/R department ensures this is taken care of.
2. 2. Helps in Recovering Overdue Payments: A/R follow-up helps all hospitals, physicians, nursing homes, etc. to recover
the over-due payments without any hassle. When there is a team which is constantly involved in the claims follow-up
procedure, it becomes easier for the healthcare providers to receive payments on time.
3. 3. Minimize Time for Outstanding Accounts: The primary objective of A/R management is to minimize the amount of
time that accounts are allowed to remain outstanding. The team tracks accounts that have not been paid, assesses a suitable
action required to secure payment, and implements procedures for secure payment.
4. 4. Claims Never Go Missing: The biggest reason for delay in payments is due to the claim not being received. This
usually happens when paper claims are lost. To avoid this, it is wise to send the claims in the electronic form. If the claim
has been followed-up and you are aware that the claim hasn't been received, then it becomes easier to send another request
for the claim soon.
5. 5. Claims Denied can be Followed Up: Depending on the denial reason, you can actually send a new claim request with
the required corrections made. By calling the insurance companies and finding out the denial reason instead of waiting for
the denial reason on mail, the A/R department can ensure that all claims are followed through till the end.
6. 6. Recover Claims Kept Pending for Information: Sometimes claims are kept pending for a certain amount of time due
to additional information needed for the member. By following-up properly the A/R team can inform the member about
the situation and then a suitable action is taken so that the process can be sped up.
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 Telephone Follow-up
Telephone contact is the best way to obtain the information about the status of
outstanding claims, Speaking with an insurance representative allows for interactive
communication. Important for determining the exact requirements for payment of the outstanding
claim. Ask all the pertinent questions necessary for you to ascertain why the claim was not paid in
a timely fashion and what the insurance carrier required to process and pay the claim.
 Written Follow-up
Written follow-up provides a low-cost alternative to telephone contact. The follow-up
letter should contain all relevant claim information (including the original filling date) and a copy
of the original claim. This approach is very effective for claims the insurance carrier has lost,
delayed or misdirected. Because of filling requirements set by insurance carriers, follow-up letters
should be sent as soon as a reasonable period of time has elapsed without receipt of payment from
the carrier (usually 30 or 45 days).

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30 Days 60 Days 90 Days

120 Days 180 Days Over 180 Days

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1) IVR/AVR Follow-up (Interactive voice response/Automated voice
response)
2) Direct interaction with Insurance representative

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 Call the appropriate phone number for the Insurance Company
o If the number is not reachable make a note of it.
o If it reaches an IVR, listen the entire options listed by the IVR carefully.
o Select the most appropriate option to reach a representative for verifying eligibility, claims or other
info, as required.
 For all Medicare carriers, claim status should be checked only through the IVR.
 Usage of * and # signs has significance with IVR calls. These signs should not be ignored when prompted for.
In general, IVR of different carriers differ in their own steps. Therefore, listening the IVR instructions carefully
is vital and would definitely yield good results, if followed as instructed
General
1. Most IVR systems will first ask for the Tax ID# or provider#, enter the required.
2. If he provider# has alphabetical characters, enter the option to get the help from the IVR on how to enter
alpha characters and enter accordingly.
3. The patient's ID# might also have alpha characters, in this case follow the IVR instructions and enter the
ID# carefully.

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 Call the appropriate phone number for the Insurance Company
 For all Medicare carriers, claim status should be checked only through the IVR. Only denials
and other issues should be verified with the rep
Self-Introduction:
 When an insurance rep comes on the line, greet him/her accordingly and introduce
yourself as a representative of the provider's billing office, giving your name.
 Tell her the reason for call.
 Example: "Good Morning Mm 'm/Sir, my name is Kevin, I'm calling from Dr
XYZ's billing office. I'd like to check claim status/eligibility for a patient.
 As a common procedure for provider verification, the insurance carrier rep will first request
for the TAX ID# or the provider#, in order to reveal any information. The requested info
should be given to prove that the call is an authenticated one.
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Verification procedures

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 If you are verifying eligibility, the rep will ask for patient's ID#, name and DOB (Date of birth).
Sometimes, the rep might even ask for the group# or plan#. This info should be provided to help the
rep locate the patient's file.
 Once the insurance rep locates the patient's file, get the patient's coverage effective date and verify
the patient's current eligibility.
 If the patent's coverage is terminated, get the termination date.
 Verify if the insurance carrier acts as primary or secondary for the coverage period.
 Ask if they have any other insurance coverage info for the patient
 Get the correct claim mailing address, filling limit and processing time for the claims, the direct
phone# to contact the corresponding customer service center to check claims and other related info.
Questions to be asked to Rep:
1. May I have the denial date for this claim?
2. May I have the effective/termination date of patients policy?
3. Could you please fax/mail me a copy of the EOB?
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 If you are verifying claim status, the rep will ask for the patient's ID# and name.
 Once, the insurance rep locates the patient's file, he/she will ask for the DOS (Date of
Service) and the total billed amount. Even the Dr’s name on the claim may be required for
this purpose.
 You may get one of the status from the below three,
Paid Claims

Un-paid Claims

Claim In Process

Claims not on file

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 If the rep says that the claims is paid, get the paid amount, check#, check date, the
bulk amount of the check and the mailing address of the check. Ask if the check was
cashed and if so, get the cashed date.
Questions to be asked to Rep:
1. Could you please tell me the check# and check date?
2. How much was the allowed amount for the claim?
3. Can you please tell me how much was paid for this DOS?
4. Are there any write off on this claim?
5. What would be patient's responsibility?
6. Can you verify the pay to address for me please?
7. Was the check cashed?
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 If the check was issued to an incorrect address, inquire why the check was sent to that address and ask the rep
to verify the address, they have for the provider. Then, ask the rep to make a stop payment on the check and
reissue a new one to the correct address.
Questions to be asked to Rep:
1. Could you verify the pay to address for me please?
2. Can you go ahead and update your records if I give you the correct pay to address for the
provider over phone?
3. Could you please give me the fax# and can I go ahead and fax W9 form to your attention?
4. Please fax us a copy of the cancelled check if the check has already been cashed.
5. Could you please put a stop payment for this check and reissue the check to the correct
address?
 If the check was issued to the correct address, but if we have not received any EOB (Explanation of
Benefits), ask the rep to send us a copy of the check and duplicate EOB. Try to get it faxed or mailed to
us at the earliest.
Questions to be asked to Rep:
1. Could you please fax/email us the copy of the Check and EOB?
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 If the rep says that the claim is denied, get the exact denial reason. If the claim can be adjusted and sent for a
reprocess, over the phone, get it done. Get the claim control# for our reference, which would help in future
follow-ups.
 If the rep says that the claim is pending or suspended for more info, get the actual info they need to get the
claim processed.
 If the claim needs to be corrected and refiled with any additional info, get all the details of the info they need, to
get the claim reprocessed for payment. Verify if they have a different review or appeal address to submit the
refiles claim.
Questions to be asked to Rep:
1. May I have the denial date for this claim?
2. May I know the actual denial reason for this claim?
3. Would you be able to Re-process the claim if I adjusted and requesting over phone?
4. Could you please share the Claim Control# for our records?
5. Could you please tell me the information required to process this claim?
6. May I have the Fax number please?

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 If the res says Claim in process, get the date of receipt of the claim, processing time.
Questions to be asked to Rep:
1. Can I have the date on which the claim was received?
2. How long would that take to process this claim?

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 If the rep says that the claim is not on file, verify if their claims mailing address matches with
the one in out records. If it differs, note down the correct mailing address and get the filling
limit and processing time for the claims. Ask if the claim can be faxed and if so, get the fax#
and name or dept, to whom the claim should be faxed.
Questions to be asked to Rep:
1. May I have the claims mailing address?
2. Could you please give the fax# and can I go ahead and fax it your attention?
3. Is patient eligible for the DOS?
4. May I have the filling limit for this claim?

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Required Information's:
 Date of forwarding of the claim to the payer
 Payer phone number
Question to be asked to Rep:
1. Could you please tell me the date on which the claim was forwarded to
the payer?
2. Can I know the phone number for the payer please?

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Required Information's:
 Date of denial
 Re-filling and appealing address
 Verify timely filing limit
 Fax number
Questions to be asked to Rep:
1. May I have the denial date and the filing limit for this claim?
2. Can I have the address where I need to appeal for this claim?
3. Could you please give me he fax# and can I go ahead and fax it to your
attention?

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Required Information's:
 Date of denial
 Details of the non covered service
 Check if patient can be billed
 EOB request
Questions to be asked to Rep:
1. May I have the denial date for this claim?
2. Could you please tell me the services that are not covered under this plan?
3. Can we go ahead and bill the patient for this claim?
4. Can I get a copy of this EOB foxed/mailed to me please?

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Required Information's:
 Date of denial
 Information on primary insurance if the rep has with their system
 Fax number
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Would you be able to Re-process this claim if I were to fax you the
Primary EOB?

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Required Information's:
 Date of denial
 Information of the other insurance If they have on their file
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Would you be able to tell me If the patient has any other insurance?
3. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Date of denial
 If possible date of Capitated contract
 Request for EOB
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. May I have the date of Capitated contract?
3. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Date of denial
 Check if there is any Auth in the software mentioned for the DOS
 Check if they have an Auth on file for any hospital claim for the same DOS
 Fax number
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Could you please tell me if you see any authorization# for the same DOS for the hospital claim?
3. I have a authorization# in the system, could you Re-process the claim if I give this number to you
now?
4. Would you be able to Re-process this claim If I were to fax you the claim with authorization
number?
5. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Date of denial
 Check if there is any referral on the software mentioned for the DOS
 Check if provider is participating
 Fax number
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. I have a referral# in the system, could you Re-process the claim If I give this number to
you now?
3. Would you be able to Re-process this claim If I were to fax you the claim with referral
number?
4. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Date of denial
 Major procedure to which it has been bundled
 Can we appeal with medical notes
 Fax number
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Could you please tell me to which major procedure the claim has been bundled
to?
3. Can I have the address where I need to appeal for this claim?
4. Could you please give me the Fax# and can I go ahead and fax it to your attention?

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Required Information's:
 Date of denial
 Ask if provider is the PCP
 If not ask for the PCP's name and phone number
 Insurance fax number
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Would you be able to reprocess this claim if I give you the referring
physician's name and UPIN#?
3. Can I have your fax number?

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Required Information's:
 Date of denial
 Correct provider info
 Fax number
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. I have the correct provider# in the system, could you Re-process the
claim if I give you this information?
3. Can I have your fax number please?
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Required Information's:
 Date of denial
 Allowed amount
 Verify the primary payment details
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. May I know the allowed amount for this claim?
3. Could you please tell me how much did the primary paid on this claim?
4. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Date of denial
 Correct diagnosis Code
 Fax number
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Could you please tell me which is correct diagnosis for this procedure?
3. Can I have your fax number please?
4. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Date of denial
 Correct modifier
 Ask for Fax number
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Could you please tell me which is correct modifier for this procedure?
3. Can I have your fax number please?
4. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Date of denial
 Pre-Existing condition
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Could you tell me the condition that was classified as pre-existing for
this patient?
3. Could you fax/mail me a copy of the EOB?
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Required Information's:
 Date of denial
 Appeal with medical notes
 Fax number
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Can I go ahead and send the appeal with medical notes?
3. Can I have your Fax number please?
4. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Date of denial
 Appealing address
 Verify timely follow-up time
 Fax number
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Can I go ahead and send the appeal with proof of timely follow-up?
3. Could you tell me the follow-up time for this claim?
4. Can I have your fax number please?

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Required Information's:
 Date of denial
 Primary DOS to which the claim is denied as Duplicate
 Appeal with Medical notes
 Fax number
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Can I have the details of the primary procedure to which claim is
duplicated?
3. Can I go ahead and send the appeal with Medical notes?
4. Can I have your fax number please?

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Required Information's:
 Date of denial
 Offset DOS details
 Amount Offset
 EOB request
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Could you give he details of the DOS offset to?
3. How much was offset to?
4. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Date of denial
 Details of the information required?
 Fax number
Questions to be asked to Rep:
1. May I have the date this claim was denied?
2. Could you tell me the information required to process this claim?
3. May I have your fax number please?

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Required Information's:
 Processing date
 Provider In or Out of network
 Break-up of the benefits
 EOB request
Questions to be asked to Rep:
1. May I know the date on which this claims was processed
2. Is the provider out of network?
3. Could you please tell me ho much was processed towards the deductible?
4. Could you fax/mail me a copy of the EOB?

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Required Information's:
 Check If provider is participating
 Payment details
 EOB request
Questions to be asked to Rep:
1. May I know when was the claim paid to patient?
2. Can I know how much was paid to the patient?
3. Is the provider participating? Could you fax/mail me a copy of the
EOB?
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Thank you
All the best

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