How Claims are reviewed


I saw a comment that suggested that a lawyer was reviewing claims to deny them for Medicare. So it prompted me to describe what happens in the claim department at pretty much any insurance gig.

Lawyers are not there to process, review claims. They are there to litigate if a suit should occur, or review laws whether new or changing. It is entirely possible that a person who passed the bar and has experience with health law would take on the job of CRS, but it is not to find ways to deny the claim. There are rules and they must be followed, if they are not - then the Lawyer will be needed!

Medicare and any Health Plan Insurer has clear rules (okay the “clear” word is questionable, I know). The insured may or may not know what those rules are but for sure the plans do. Insured should keep copy and records of the policy they own and it’s rules. Sometimes mistakes happen, and a claim can be denied. Those are less common today since coding and processes are generally standardized across the industry. You plan and Medicare make available the rules and limits that apply to you. Also they have a process for Appeals & Grievances. Here is just one example for Medicare: If a Medicare health plan denies service or payment, in whole or in part, the plan is required to provide the enrollee with a written notice of its determination. Additionally, Medicare health plan enrollees receiving covered services from an inpatient hospital, skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility have the right to a fast, or expedited, review if they think their Medicare-covered services are ending too soon. Plans and providers have certain responsibilities related to notifying beneficiaries of Medicare appeal rights.

And here is the process for resolution: A Claims Resolution Specialist (CRS) is responsible for following regulatory and internal guidelines, and applies them to the payment and or adjustment of claims and resolution of reconsideration requests and provider call resolution.

A CRS (or Lawyer lol) knows and follows:
Principles and practices of managed health care, health care systems.
Principles and techniques for handling customer service issues.
Knowledge of Revenue Codes, CPT-4/HCPCS, ICD-9 and Medi-Cal codes.
Knowledge of HCFA (CMS-1500) and UB claim forms.
Knowledge of industry pricing methodologies, such as RBRVS, Medicare/Medi-Cal Fee Schedule, etc.
Medical Terminology.
Benefit interpretation and administration.
Medicare/Medi-Cal guidelines and regulations.

When a claim just gets in and out without issue the process is pretty cut and dry: Claim is submitted by provider, claim is entered into system, system verifies member, provider, location, dates, coding detail, determines payment schedule based on benefits, and if all is in order - payment is sent for the service and an EOB (explanation of benefit) is sent to the member. If all is NOT in order, the the EOB will be sent with an explanation, the process to follow if an appeal is desired, etc. Often, the provider can resolve a denied claim by correcting the submission, and resubmitting it.

So - If a lawyer is processing claims and the job is to find ways to deny your service I’d get a new plan. There are probably less costly ones available. I have some experience with public agency insurance, and RULES are of utmost importance. The lawyers in the house did not process claims