Is that true? 14 Common Pediatric Billing Truths and Myths

If you are overseeing a billing team but you haven’t done the job yourself, you may want to know if what your billing team is telling you is accurate. Some things may seem like excuses and others may seem outright bizarre.

As a pediatric billing company, we have pretty much seen it all after working with hundreds of pediatric practices across the country.  We’ve heard wacky policies from payers that are indeed true, and have taken over other billing teams that have said things that were definitely not true.

This guide will provide you with the right pediatric billing guidelines to help you validate or debunk some of the things you may have heard that leaves you questioning your billing company. 

Things Your Biller Might Be Telling You That are TRUE

Truth #1: A claim can be denied for being out of network even when you have always been in network.

This happens a lot more than it should. You aren’t REALLY out of network, but something somewhere got messed up, and now a particular provider, or even your whole office, is out of network. To combat this, you must get your provider rep or credentialing company involved and the backlog should be paid. When this happens, keep good records and fight hard to get these claims paid. The battle for these claims can take months to fight.

Truth #2: A patient’s insurance depends on her parent’s birthday.

With two commercial policies, the child’s primary insurance is the one with the parent whose birthday comes first in the year. Age doesn’t matter; it’s just when their birthday is. One thing to note is that government payers are always last, regardless of birthday.

Truth #3. When codes are added late, you can’t just send them right away. 

You can’t just bill a vaccine because it didn’t make it on the original claim. You will need to wait for the claim to be processed and then send a corrected claim with the vaccine.

Truth #4. The payer can’t help – every time I call the insurance company with a question, I get a different answer. 

When my billing team gets an answer they don’t like, they pick up the phone and call again until they get someone who does know what they are talking about. If they can’t find that person and the advice they get doesn’t seem right, they will file appeals, send medical records, submit AAP hassle factor forms, or even involve the state board of insurance. Your team doesn’t have to accept bad advice from insurance reps but it can take a lot of work to get to the correct answer.

Truth #5. It’s nearly impossible to get claims paid correctly for twins.

For the life of me, I cannot figure out why this is so hard, but it is. In fact, several years ago, the AAP called for examples they could take to payers to help fix this problem. When there are twins, it is very common for the payer to either pay for one child only or pay for one child twice. Trying to untangle the error is time-consuming and difficult.

Truth #6. I sat on hold with the insurance company for two hours and then they hung up. 

Some companies have atrocious hold times, and getting disconnected is infuriating. More and more companies are adding online options for handling questions and communications, and if you call some companies after hours, you get to leave a message, and someone will call you back. In my experience, oftentimes, they really do call you back – usually first thing the following day.

(Sometimes) Truth #7. If you code that add-on code that never pays, the whole claim will be rejected. 

United loves to do this. If you put a specimen handling on there, they reject the entire claim. What the heck? We always tell people to bill for everything you do – when we see these rejections, we end up removing them from the United claims only so they can get in and get paid. Don’t just accept this as truth and decide to leave things off of a claim.

Things Your Biller Might Be Telling You that are FALSE

Myth #1: Sick and Well on the same day never pays. 

Some plans may pay less on the sick visit and some diagnoses won’t count, but sick and wells on the same day should be billed and paid. Examples of diagnoses that won’t pay on the same day include diaper rash and hemangioma. Strep throat? Ear infection? Yes, this needs to be paid.

Myth #2: Claims don’t have to go out every day. 

The only way to have healthy cash flow is for claims to go out each day. The only time this isn’t true is if you have some bad practices in your team where the nursing staff doesn’t complete tasks on time. If this happens, then claims should be held until all codes are added, and you will need to address and correct this bad habit so claims can go out every day.

Myth #3: All babies are covered under their parent’s insurance for the first thirty days.

Generally, this is true, but some policies and states don’t allow this. Pennsylvania has an entire law around when this ISN’T true. Our preferred newborn workflow is to allow thirty days for babies to be added and then bill under the patient.

Myth #4: If an insurance company wants their money back, cut them a check. 

Payers send lots and lots of refund requests. One of three things happens when we start to work on a request. They sent it in error and reprocessed the request. They sent the refund request too late and can’t legally take back the money, or they just take it from another claim. If you send a payment AND they take it back from another claim, you have now double-paid the claim. The exception is government payers – when you get a refund request from a government payer, they generally have longer to request the money and can fine you if you don’t pay it back in time.

Myth #5: You can never bill Medicaid patients for anything.

There are circumstances where you can bill for non-compliance and some plans even have small amounts of cost-sharing with copays as little as $5.00. Don’t simply write off every Medicaid balance without reviewing the charge and the EOB you received.

Myth #6: If something is on the fee schedule or the rep says it is covered, it is covered. 

The only way to know for certain that something is covered is to bill it and be paid for it. Sometimes, there are behind-the-scenes patient coverage decisions that preclude them from certain codes, and sometimes, the payers will only pay some codes for specific provider taxonomy codes.

Myth #7: Certain codes never pay, so leave them off. 

Bill for everything every time. If a plan suddenly covers capillary draws or specimen handling, you will never be paid for it if you never bill for it.

How Can You Verify What You Are told?

The next time you hear something from your billing team that you aren’t sure is accurate, follow these pediatric billing guidelines and simply ask more questions. Get a payer’s policy in writing or make sure all avenues have been exhausted. Not sure where to start? A good rule of thumb is that if something should pay that doesn’t, it’s worth questioning and fighting for.

As you can see, it may be pretty difficult to know what is true and what isn’t, and that can be incredibly frustrating when trying to figure out why some claims aren’t paid yet.

Now that you have seen some of the truths and myths the Altus team has encountered, you should have a better sense of what is and isn’t true so you know how to better lead your billing team.

Your question didn’t make the list? Schedule a quick 15-min discovery call and we will be happy to address it.