Nicole Marinescu

Mitigate Financial Risk: Sleep Study Case

Dave has a stressful job. Dave is responsible for processing claims and accounts receivable, ensuring the office is paid by insurance companies for services rendered. Submitting claims to insurance companies requires a lot of information, including procedural code(s) (CPTs) and diagnosis code(s) (ICDs). These codes, in near-infinite combinations, can represent a dizzying number of pitfalls amongst insurers. And of course, this information must be complete and accurate ALL THE TIME! Validated against payer medical policies, vetted for mistakes, scrubbed for accuracy, etc. Unfortunately even a small mistake can lead to disputes, late payments, and (ultimately) denials. This adversely affects cash flow for Dave’s organization, adding more stress to his work.

Recently Dave noticed a trend in several denials. Requests for a certain procedure – sleep studies – were consistently denied. Dave investigated the denials for a specific patient: John Dough.

John’s career as a high school math teacher has been adversely affected recently because he had been suffering from morning headaches and rarely feels as though he wakes up energized for the day ahead. John’s wife, Jane, noticed several times throughout the night, when John slept, his breathing was frequently interrupted. Jane also knows that John snores loudly. John’s doctor believes John suffers from obstructive sleep apnea (OSA), and that treatment could dramatically improve his health and quality of life. Equally important, John’s wife could benefit from uninterrupted sleep and a less irritable spouse!

Dave recognizes that John would need a sleep study to determine if the patient is experiencing OSA. Unfortunately Dave noticed a pattern where payment for sleep studies were consistently being denied. This puts patients like John in a predicament: John needs a treatment for OSA, but the treatment cannot begin until after a sleep study has been done, and right now the insurance company will not pay for it. This is a painful conundrum for Dave and his office.

At Next Health Choice, we provide Benefits & Eligibility verification which lets us find solutions to Dave’s problem. These could be searching medical policies, using incorrect CPTs when billing, or something simple like billing an expired plan. Next Health Choice works with clients to ensure they get compensated for their services, so that instead of waiting until a claim is billed, we mitigate your risk before you even perform the service. Don't perform another service and hope you get it right. With Next Health Choice, know you're going to get paid. Just like our sleep study scenario, help John (and his wife) sleep at night, and Dave’s facility gets paid!

More patient time, less office work

Get in touch with Next Health Choice today to learn more.


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