new job update (kind of long)
I have been meaning to post about my job for a little while now, but never get around to it...
My title now is Claims Validator I. I work for Omnium Worldwide, Inc., which actually just got bought by West Asset Management (of West Corporation) - our official date to change the name we are using externally is October 1st. Our payroll has already changed, and all of our benefits except health insurance, which will be at the end of the year. Both are good companies to work for (though it was disappointing to see what West's health benefits are for how large of a company they are).
Most people know both companies as collection companies, as that is their main service. I do not work in collections. Never have, never will. I work in the Insurance Services division - we have several large clients in the insurance industry that we review claims for. I will not name the client I work with, that way I can write more about what I do in posts and not feel like I am potentially breaking any company rules (or federal laws, for that matter [HIPAA]). However, our client is the newest, and therefore the least profitable so far - we are still smoothing things out with their expectations and their policies and procedures. It is an ever-changing position, which I am ok with. And I really love the investigative nature of the work - even my slow days go by pretty quickly these days - it is awesome!
Our job is to find the overpaid claims that our client made and send it back to them to collect on (from the provider they overpaid). Once a month we get a tape of all the claims that the client paid in the last month. We have a group of "tech-y" people who put criteria into the system to filter out claims least likely to be overpaid and filter up claims most likely to be overpaid. How they do this, I have no idea, as none of them have insurance or claims experience, so how they would know what/how to filter is beyond me. We review the basics, dig a little deeper doing research on the patient/coverage if we have to, make a phone call if we have to, then reject it if it was paid correctly and list it if it was overpaid. Underpayments? Not our department - those get classified as paid correctly. That was a hard mindset to get into - but you figure, there are totally different companies/teams out there looking at those - our just is strictly to find overpayments the client made and help get their money back.
A lot of people seem to think, how can there seriously be a market for this? Do insurance companies really overpay that often? Oh yes. If you don't work in the field you have no idea. Our client is one of the largest insurers. They have 12 vendors (including us) that work for them to identify overpayments. For just our company, just this one client, just our office with 13 people in WDM, we have sent in over $1 million of overpayments since the beginning of the month. So yes, it happens extremely frequently, and is a profitable market to be on this end of. How does it happen? Anytime human hands touch anything there will be mistakes. Thankfully (for my job), a lot of medical claims are still processed manually, or the ok to pay is done manually. Overlook one date or one note on the account and you pay out when you shouldn't.
Coordination of Benefits, or COB, is where the most mistakes are made when claims are paid. There are many set rules as to when a patient has more than one insurance coverage, who is supposed to pay first. I have known most of these rules from working in the billing office for IHP, and take for granted that it is general knowledge, I think. Many people do not know that there are set guidelines and laws in place that determine which of their insurances will pay first. I think some people still think they get to pick who is their primary and who is their secondary insurer, but it is not so. A few examples:
1)If you have your own insurance as a subscriber, it will be primary to a policy you may be on as a dependent (if you are on spouse's or a parent's insurance) - you do not get a say in this.
2)Unless the policy you are the subscriber on is not through active employment (retirement plan, COBRA, self-funded) - the plan held through active employment is primary.
3)If both parents insure a child, the parent whose birthday is first in the year is primary. No, you do not get to choose who will cover the child as primary. (this is why I will never put Jarin on my insurance, as Madd's is way better, but my birthday comes first in the year). The only exceptions to this rule are divorce cases/court orders.
4)If you work 2 jobs and are insured through both, the plan that has covered you longest is primary.
There are a few more that don't really apply to too many people.
And there are several rules just for Medicare itself. Depending on why you have Medicare (age, disability, End Stage Renal Disease/ESRD), whether you are actively working or retired/on COBRA, and how large your employer is, Medicare may or may not be primary. This always requires a phone call to Medicare to verify all information.
So, with all these rules, and taking into account that the patient does not always disclose information on one with the other, and that these claims are all worked manually at some point, there are many, many mistakes made and claims paid out that shouldn't be.
So, I get paid pretty decent with a 3.50/hour raise from my old job (I'm over $30K now!) and we can earn bonuses starting next month - go me!!! I am excited for that - knowing you can earn bonus based on performance is that much more motivation to get it done. I fully intend to have a bonus check coming to me in October, even if it is only for $20! haha It is nice to have a job I look forward to doing every day, and that I look forward to going in to, and that even when I am having a not great day it goes by quickly. Yay for my new job! More on it another time.
My title now is Claims Validator I. I work for Omnium Worldwide, Inc., which actually just got bought by West Asset Management (of West Corporation) - our official date to change the name we are using externally is October 1st. Our payroll has already changed, and all of our benefits except health insurance, which will be at the end of the year. Both are good companies to work for (though it was disappointing to see what West's health benefits are for how large of a company they are).
Most people know both companies as collection companies, as that is their main service. I do not work in collections. Never have, never will. I work in the Insurance Services division - we have several large clients in the insurance industry that we review claims for. I will not name the client I work with, that way I can write more about what I do in posts and not feel like I am potentially breaking any company rules (or federal laws, for that matter [HIPAA]). However, our client is the newest, and therefore the least profitable so far - we are still smoothing things out with their expectations and their policies and procedures. It is an ever-changing position, which I am ok with. And I really love the investigative nature of the work - even my slow days go by pretty quickly these days - it is awesome!
Our job is to find the overpaid claims that our client made and send it back to them to collect on (from the provider they overpaid). Once a month we get a tape of all the claims that the client paid in the last month. We have a group of "tech-y" people who put criteria into the system to filter out claims least likely to be overpaid and filter up claims most likely to be overpaid. How they do this, I have no idea, as none of them have insurance or claims experience, so how they would know what/how to filter is beyond me. We review the basics, dig a little deeper doing research on the patient/coverage if we have to, make a phone call if we have to, then reject it if it was paid correctly and list it if it was overpaid. Underpayments? Not our department - those get classified as paid correctly. That was a hard mindset to get into - but you figure, there are totally different companies/teams out there looking at those - our just is strictly to find overpayments the client made and help get their money back.
A lot of people seem to think, how can there seriously be a market for this? Do insurance companies really overpay that often? Oh yes. If you don't work in the field you have no idea. Our client is one of the largest insurers. They have 12 vendors (including us) that work for them to identify overpayments. For just our company, just this one client, just our office with 13 people in WDM, we have sent in over $1 million of overpayments since the beginning of the month. So yes, it happens extremely frequently, and is a profitable market to be on this end of. How does it happen? Anytime human hands touch anything there will be mistakes. Thankfully (for my job), a lot of medical claims are still processed manually, or the ok to pay is done manually. Overlook one date or one note on the account and you pay out when you shouldn't.
Coordination of Benefits, or COB, is where the most mistakes are made when claims are paid. There are many set rules as to when a patient has more than one insurance coverage, who is supposed to pay first. I have known most of these rules from working in the billing office for IHP, and take for granted that it is general knowledge, I think. Many people do not know that there are set guidelines and laws in place that determine which of their insurances will pay first. I think some people still think they get to pick who is their primary and who is their secondary insurer, but it is not so. A few examples:
1)If you have your own insurance as a subscriber, it will be primary to a policy you may be on as a dependent (if you are on spouse's or a parent's insurance) - you do not get a say in this.
2)Unless the policy you are the subscriber on is not through active employment (retirement plan, COBRA, self-funded) - the plan held through active employment is primary.
3)If both parents insure a child, the parent whose birthday is first in the year is primary. No, you do not get to choose who will cover the child as primary. (this is why I will never put Jarin on my insurance, as Madd's is way better, but my birthday comes first in the year). The only exceptions to this rule are divorce cases/court orders.
4)If you work 2 jobs and are insured through both, the plan that has covered you longest is primary.
There are a few more that don't really apply to too many people.
And there are several rules just for Medicare itself. Depending on why you have Medicare (age, disability, End Stage Renal Disease/ESRD), whether you are actively working or retired/on COBRA, and how large your employer is, Medicare may or may not be primary. This always requires a phone call to Medicare to verify all information.
So, with all these rules, and taking into account that the patient does not always disclose information on one with the other, and that these claims are all worked manually at some point, there are many, many mistakes made and claims paid out that shouldn't be.
So, I get paid pretty decent with a 3.50/hour raise from my old job (I'm over $30K now!) and we can earn bonuses starting next month - go me!!! I am excited for that - knowing you can earn bonus based on performance is that much more motivation to get it done. I fully intend to have a bonus check coming to me in October, even if it is only for $20! haha It is nice to have a job I look forward to doing every day, and that I look forward to going in to, and that even when I am having a not great day it goes by quickly. Yay for my new job! More on it another time.