The first thing to note is that most of these companies don’t work denied or underpaid claims on behalf of their clients. They either pass that work onto the client, or they charge a much higher than advertised rate to include that service. Secondly, when calculating their ‘approved claim percentage’, they count partially approved claims. However, by any reasonable standard, a partially approved claim is not an approved claim.
Another way these companies achieve high first-submission approval rates is by using an automated system, which flags claims before submission if they are more likely to be denied. Then, they send those claims back to the provider and tell them to adjust them. They don’t necessarily say what’s wrong with them or how to fix them. They leave the clinicians to figure it out. The result is that clients are left personally dealing with, what are essentially, pre-denied claims. In other words, for the clinician, the work is the same. They’re still dealing with denied claims, just sent to them from their own billing company.
Another problem with the ‘first-submission approval rate’ is it becomes the primary success metric for companies that use it. Essentially, they become more concerned with claim approval rate than maximizing clinician reimbursement. As a true billing company, we know better than anyone that there are plenty of occasions where a denial can be fixed quickly by simply removing a code and losing out on that potential reimbursement. However, that’s not what a billing company should do. Real billing requires persistence. It requires following up with the insurer, explaining the issue, and finding the solution that gets the clinician their full, owed reimbursement. That’s billing.
What’s important to remember is that insurers don’t want it to be easy. They don’t want it to be something that can be easily automated because that would hurt their bottom-line. The true billing work is in noticing abrupt changes when they occur and persistently following up to correct them on behalf of your clients.