December 08, 2018

Pay. Bed. Continued.

It was a better day, but to explain exactly why it was better, you need to know why yesterday sucked the chrome off a trailer hitch.  So here we go.


The life-cycle of a claim is convoluted even before it reaches my computer screen.  It's like this: you go to the doctor to have that... thing... on your shin looked at ("Is it supposed to have a face, doc?" ICD-10 S89.80XA).  After he finishes flame-sterilizing his examination room (ICD-10 T31.99), his office manager bills your insurance company (ICD-10 G93.9x)... which just happens to be the company I process claims for.  Whatta coinkidink!

Assuming the claim is sent electronically, the system attempts to process it automatically.  If that attempt fails (and there's a good chance it will), it gets shuffled into the Big Bucket o' Claims that gets dumped into the Intartubez where it sits until I or one of my cow-orkers has it land in our laps (ICD-10 S38.01XA).  We attempt to process it.. and remember, these are the ones that couldn't be done by the Master Control Program... and either we can or we can't.  If we can't, we have to detail what the problem is and send it to specialists at the insurance company's TM Department.  There, they fix what's wrong and send it back.  At which point we should be able to complete the claim and get the doctor paid.

That's the way it's supposed to work.  Now let me tell you what's actually been happening.

Somewhere after the Big Bucket o' Claims but before it got to us, there was a glitch.  For whatever reason, about two-thirds of all claims were sent to the TM Department whether they needed to be or not.  Now, the TM Department is not what you would call tolerant of mistakes... you do NOT want to send a contract problem to enrollment, for example... so when they came in on Monday morning they reacted as one might expect.  All of these claims got a message put in the notes field stating, in effect, that they were sent in error and need to be processed according to the usual rules, then they were dropped back into the Bucket.

And that's when the fun began.  See, we tried to process the claims according to rules, but just like any claims there were occasional problems... a new physician has joined a clinic and hasn't been "associated" with it in our system, can you fix that please?... which we duly sent back to the TM Department.

And they promptly sent them back with the same message.  And by promptly, I mean next day.  Better yet, they didn't actually do anything to them.  I've taken to sending them back with a painfully detailed explanation of the problem in the memo field: "This doctor, David Smith, needs to be added to the rolls of James Clinic so this claim can be paid" instead of "firing edit 999, please advise" which has worked perfectly fine for the past three-plus years.  And at least half the time, THOSE claims came back with the same message.

So all of that is bad enough.  But here's where it gets REALLY REALLY FUN!  Long Term Care claims (LTC) are a huge part of our daily drops... if we get 4000 claims in a day, 2500 of them will be LTC.  And most of those are for Personal Assistance Services... back when I first started at this job, PAS claims were the greatest thing ever!  When I was really rolling, I could easily do 45 or 50 of them in an hour.  But then about a year or so ago, a new policy was instituted by the client that required any PAS claim with a certain flag set had to be held overnight so the automagic system could... I dunno, check a contract or something.  Since the claims aren't actually finished, we don't get paid for them until they ARE done.  Okay, whatever... at least we get them completed the next morning.  No big deal.

How does this flag get set you may be asking?  Well, if we have to actually enter the provider into our system, that's one big way... the electronic form we work from is fine, but for whatever reason OUR ops program didn't get the info carried over.  If there's multiple providers under the same name, for example, the system won't carry it over.  This happens a lot with some of the bigger LTC companies that might have offices in four or five cities.  They should all fall under the banner of "Bob's Bunny Care", and in fact do, but the system has "Bob's Bunny Care - Marengo", "Bob's Bunny Care - Union", "Bob's Bunny Care - Elwood", etc etc etc

Another way that flag will be set is if the claim comes to us via the TM Department.  Yeah, you see where this is going.  On Thursday, I pulled over 120 LTC claims in four hours or so, and almost all of them I had to hold overnight.  Well, so what?  At least I'll get them Friday morning, right?  Even though I knew those claims were going to be held, absolutely knew it... they still took time to deal with.  In fact, it takes very nearly as much time to get one of these claims to the point where you can hold it as it does to actually COMPLETE the claim.  And then the next day, even though the claim is almost done, you still have to spend time finishing it up... and the total time between the two days is LONGER than if you could have just done it all in one go.

So those 120 claims that should have been done on Thursday but weren't cost me time that could have been better spent on NEW claims on Friday.  Annoying enough, but when I mentioned this fact to one of the supervisors and explained that I had basically made half minimum wage on Thursday because of it, she got very very quiet.

Jump to Friday night.  Wonderduck is very literally the only person working the State I was pulling claims from... and they were LTC.  But there was a difference... all of the broken claims had been removed and sent back to the TM Department to get them fixed for easy processing.  I still had about 60 or 70 claims that wound up being held over for Monday, but the "good" claims were all like the Old Days.  So.  Better.  But why couldn't they have done that on Thursday?  I don't know, and I probably won't ever know. 

Posted by: Wonderduck at 11:59 PM | Comments (4) | Add Comment
Post contains 1112 words, total size 8 kb.

1 Bonus points for earworming me with "Disappointed." Bravo!

So the whole claims system is a Rube Goldberg machine, I'm gathering. Yikes.

Posted by: GreyDuck at December 09, 2018 11:37 AM (rKFiU)

2 No, it works perfectly well... when the client isn't mucking around with it.

Posted by: Wonderduck at December 09, 2018 07:15 PM (PzbzM)

3 So what you're saying is, someone finally got yelled at for being lazy.  Nice!

Posted by: Rick C at December 10, 2018 09:25 AM (Q/JG2)

4 That is one angry ape.

Posted by: Ben at December 10, 2018 12:15 PM (osxtX)

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