Emergency Medicine Groups billing and accounts receivable

Emergency medicine bills patients it will never see again, for care nobody authorized, to plans it usually has no contract with — which makes eligibility, level of service and out-of-network the three fault lines.

Where the money leaks in emergency medicine groups

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Eligibility unknown at the time of service, so the claim goes to the wrong payer or none
• Level of service downcoded against the payer's own norms rather than the record
• Prudent layperson standard not applied, and a presenting complaint denied on the final diagnosis
• Out-of-network claims underpaid with no negotiation or dispute pursued
• Facility and professional claims crossing and cancelling each other

What a seat does about it

One trained person works your queue from the difficult end, from our office in Rawalpindi, Pakistan, logged into your own system on your hours. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing. Some payer contracts and some state Medicaid programs restrict or require disclosure of offshore access — check yours before placing a restricted queue on this seat (more on /security/).

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and medical coding at $2,500, on request.

The codes those turn into

Each of these is a denial code you are likely to meet working emergency medicine groups, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-109 — Wrong payer or contractor
  It went to the wrong place.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Eligibility unknown at the time of service, so the claim goes to the wrong payer or none”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and payers ultimately pay roughly 90% of claims even while using an initial denial to slow payment. Most of what sits in a emergency medicine groups AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions