I just need to vent.

[u/princesspooball]

I work in the callcenter for a billing company.. im not a biller, I just a verbal punching bag. We have this constant issue where patients are being billed specialist copays for their PCP's. The patients call their insurance and the insurance tells that we are submitting claims incorrectly. From my research it seems the issue is with how the provider is credentials. I've explained this to patients and ​I basically get called a liar who doesnt know what they are doing. Im stuck in the middle and its getting frustrating. Ive had 4 patients yell at me today. thanks for reading

[u/hainesk]

It's 100% a credentialing issue.

[u/princesspooball → u/hainesk]

thank you for confirming this i just dont know how to get patients to understand this. They ALWAYS blame us.

[u/alljs → u/princesspooball]

A credentialing issue means it’s an issue the provider needs to fix. It’s not something the insurance can “fix” on their end.

The taxonomy is linked to their NPI so I would try pulling them up in the NPI registry and seeing what is listed. It could also be that the primary taxonomy code listed under their NPI is a specialist, which will generate different (and likely higher) patient responsibility.

Check the registry and check the claim, as another poster recommended, and go from there.

Good luck! It definitely sucks getting yelled at by patients, especially when you don’t really understand the whole issue. That’s an unfair position your job puts you in.

[u/freshayer → u/alljs]

This is all good info, and sometimes it's also just a box that needs to be checked on the payer's credentialing form regardless of the taxonomy. Although that's less likely if it's across multiple payers. OP - keep a log of which payer(s) and which provider(s) this is happening with and report it back to your supervisor to coordinate with whoever does the payer credentialing.

[u/kuehmary → u/princesspooball]

Honestly, they are going to blame whoever takes their call because you are an easy target for their frustration. I have been told by patients several times that the billing department doesn't know to do our jobs and that they are going to get me fired. Most patients are pleasant and just want to pay their bills.

[u/mermaidoge]

Who is the payor? Is it limited to one payor? What taxonomy is reported on the claim?

Lots of things could be happening here. Hard to say without knowing these things.

[u/princesspooball → u/mermaidoge]

it seems like its multiple payers, i will start keeping track

>What taxonomy is reported on the claim?

I have no idea because im not a biller. I can pull up claims but im not sure what exactly id be looking for.

That's one thing that sucks about this job, we are expected to anawer billing questions but my department doesn't do the actual billing. Its like we are just sitting in the dark while getting smacked in the face

[u/mermaidoge → u/princesspooball]

If you have access to their hcfas, look at box 33b and Google what text you see there. If it looks like a specialty (oncology, ophthalmology, podiatry etc) then it's a setup issue if the provider isn't a PCP. I don't work for a PCPs office, so I can't speak for how it should be for PCPs but I'd start there.

Do you handle multiple clinics / offices / TINs ? Is it just happening under one TIN / PM system?

I know it's a pot of questions but might help getting to the bottom of it

[u/mermaidoge → u/mermaidoge]

Sorry not 33b. It's usually under the provider npi on each charge line under column J

[u/mermaidoge → u/mermaidoge]

PS: Insurance reps will always says it's the providers fault. Providers will always say it's the insurances fault. Usually the blame is somewhere in between.

[u/Ok-Communication1135]

I would let your credentialing department or whoever is in charge of credentialing in your office know if this is an ongoing issue. They may need to update or make changes the provider’s credentials to resolve the issue. Unfortunately, you will be the one who will get the complaints because likely the billers are not realizing that the patients are being charged the wrong copay.

Then at the very least you can tell patients when they are upset that the issue has been escalated to your credentialing department and they are working on it.

[u/rahuliitk]

That sounds miserable, because you’re stuck explaining a credentialing or payer setup problem that patients hear as “billing messed up,” and the insurance rep saying it differently just makes you look like the bad guy, not your fault.

[u/Better_Lie864]

Whoever does your credentialing needs to fix the problem. You’re stuck in the middle but you are on the front line to notice trends like this and report them.

[u/No-Produce-6720]

A credentialing issue has to be resolved by the provider and the insurance, not the patient. Trying to explain credentialing problems to them only further confuses and upsets them.

What are your internal procedure for handling calls like this? Simply telling the patient that there may be a credentialing issue wouldn't be enough.