What we do

Transparent Claims helps substance abuse treatment facilities and surgery centers with billing services that aids them in collecting the most money possible for services rendered. Centers don’t have time to fight with insurers 24/7. Just let the experts handle it. Our goal is to get you paid. Our motto is No Claim Left Behind and we truly mean that. Our streamlined processes speak for themselves as we keep our clients apprised of every step in our claims process. We don’t have to tell you what kinds of problems are caused when insurance companies put up a fight. It impacts everyone involved.

What types of billing services does Transparent Claims offer?

  • In-network claims.
  • Out of network claims.
  • Denied claims.
  • Underpaid/Low Paid Claims.     
  • Missed Billing Opportunities.
  • Low Grade Data.

 Here are some important things to consider:

How does this impact patients? Patients are often placed in the middle of a tough battle. The Battle of the Claims. This conflict can get quite bloody and often does. The unfortunate but common result? Little to no payments from the insurance company and the remainder of the balance being billed to the patient. Balance billing complaints rose 1000% between 2012 and 2015. Many patients don’t understand the concept of balance billing as they trust that the insurance company will cover the rate that was negotiated. This can turn into a long, ugly battle that can go on for years. High out of network rates, understandably, can be a huge shock for patients. But the bigger shock is experienced by the treatment centers and clinics that get paid a mere fraction of what they are owed.

What can happen to facilities that continue to remain unpaid or underpaid that don’t seek real help?

  • Less patients. There are only so many battles facilities can afford to fight at a time. When these centers are not being paid as they should by certain insurance companies, they have no choice other than to stop accepting insurance from such carriers. Cash pay only facilities are slowly on the rise due to such issues.
  • Closed doors. This is the fate of many treatment facilities and surgery centers. They must make money to stay in operation. If they are only getting paid a small fraction of what is due, how can they remain in business? Businesses need to generate a profit to stay in business.
  • Slow payments. These battles with insurance carriers can drag on for years. Even if these centers finally do get paid, it can take a really long time. Especially, if these centers don’t have another party that can recover these payments for them effectively and in a timely manner.
  • Patients that need help, won’t receive it. When the burden of some of these huge bills fall on the patient because the insurance company won’t pay, the patient often cannot afford any further treatment. This often will include medication. So, the centers are then forced to send the bill to collections. Good luck with that. Nothing a few dispute letters from the patient or a bankruptcy can’t clear up, and the centers will remain unpaid. The solution here is clear. Find a company that will take every single claim seriously.
  • Negotiate for much lower rates than agreed. Many facilities end up negotiating with the patients directly to salvage something. Though this method can work, it still results in being grossly underpaid.

Even if approved, can insurance companies just decide not to pay on claims at all? Is it legal?

That is unfortunately left for further interpretation and can vary by state. The scary thing is that it happens pretty often. A prime example is the incident with Health Net deciding to withhold payments from substance treatment facilities.  Due to the increasing amount of grievances levied against HealthNet by these centers, the California Insurance Department got involved and put pressure on HealthNet to settle these claims. HealthNet was acquired by Centene in 2016, who agreed to use their reserve to cover their plans. This still resulted in further denials, underpayments and slow payments. Very slow. So, the real answer here, is that it is up to the courts. Many treatment and surgery centers bring lawsuits against companies like Health Net, who stop paying their claims or take unreasonably long periods of time to pay. However, not everyone can afford to go to court.

What do treatment facilities and private specialty centers think are the solution to their claims issues?

  • Lazy Billers.Throw a ton of claims at a wall and see what sticks.’ That’s the concept. It’s a widely used tactic well-known in the sales industry. The numbers game. Some billers submit mass claims to insurance carriers and give up at the first sign of a pushback. There is not only a lack of follow-up but also a lack of tracking. So, the medical provider has no earthly idea how much effort was truly put into the research and follow-up of their claim submissions. They are only provided with the end-result but are never given any details about how that biller arrived at that result.
  • Balance Billing. Balance billing has increased tremendously over the years due to insurance companies only paying a fraction of what was agreed upon. The liability then falls back onto the patient, whom in most cases cannot afford some of the massive bills generated from their treatment. Situations such as these can discourage patients from seeking the treatment they actually need. This can often be a life or death situation for patients when they don’t receive help for their substance abuse or ongoing medical problem, when needed. Not everything qualifies for an ER visit, so that leaves patients with no options because they can’t afford to go to the treatment or surgery center for the assistance they need. The end-result can be disastrous when left with little to no options.
  • Going to Cash Pay Only. Even though Cash Pay Only Centers are on the rise, that still leaves out a lot of insured patients that centers will not be able to do business with. Take on the patient’s perspective. Are going to go to a facility that accepts your insurance or one that does not?

Paperwork. No one likes the P-word. Unrealistic demands on paperwork can often cause delays in processing, resulting in slower claim payments. Centers often feel like they have to become accountants or bookkeepers to keep track of all of the documentation. What was sent? When was it sent? Who sent it? How was it sent? Was there a response? When was the response? How long did it take to get a response? Was there a follow up? When was the follow up? How many times? What were the responses for each follow up? Was additional paperwork requested? When was that paperwork sent? We can go all day with this. We don’t have to tell you about the level of frustration that accompanies these processes when going at it alone. According to an AMA Survey of 1000 practicing physicians, 92% of them have indicated that prior authorizations lead to patient care delays. It’s not just the unpaid services that bring on the headaches but when patients go to pick up their prescriptions, there are more hoops to jump through. Say it isn’t so? That process too? Yes. For many treatment and surgery centers, it feels like insurers think their facilities exist solely to fight claims.

What is the actual solution, or shall we say whom?

TRANSPARENT CLAIMS

Our mission is No Claim Left Behind. It’s simple yet drives our point home. Our team provides real-time claims statistics once documentation is submitted, and we call on each and every unpaid claim. No batch claims here! Our organized system for effective follow-ups and tracking, results in a better rate of return than traditional methods used by competitors.

Guidelines for Brand New Treatment Centers. Contact us early so we can set you up for the big 4 – Blue Cross & Blue Shield (BCBS), United Healthcare, Aetna and Cigna. An NPI# is needed as well as in-patient or outpatient certification (varies by state or facility type). Instead of going at it alone or trusting sub-par lazy billers that do mass claim submissions with no actual follow-up, go with a company you can count on. A company that cares about your billing issues and looks at every situation, claim-by-claim. We stand by our mantra, No Claim Left Behind. Contact us today for a consultation so we can help.