Case Study 2 — Page Twelve: A Composite

Constructed. The practice, the payer, and the figures are not real. The failure — a payer requiring something it had published, a practice rejecting against it for over a year, and the answer sitting in a PDF in a provider portal — is ordinary, and it is the cleanest illustration in this book of the difference between information being available and information being found.

Background

Section 25.9 listed seven rejection causes and ended the list with an unsatisfying seventh:

MISSING REQUIRED FIELD — varies by payer. The payer's companion guide says which.

This is a practice that never opened one.

The composite

Constructed.

A mid-sized specialty practice. One payer — not its largest, but a meaningful share of its volume — begins rejecting a category of claims.

The rejection message is generic. Something to the effect of missing or invalid data, with a segment reference the billing office does not read.

The practice works them. Somebody opens each rejected claim, tries something, and resubmits. Some resubmissions succeed, because the biller happened to populate the missing element while editing something else. Some do not, and get tried again.

Over time an oral tradition develops. "For that payer, put the ordering provider in even when there isn't one." Nobody knows why it works. It works about two-thirds of the time.

Fourteen months

(Constructed.)

The rejections continue at a steady rate. They are worked. Nobody escalates, because each individual rejection is small and the queue is being kept current — which is Chapter 21's Case Study 1 in a different category: a team competently working something that should not exist.

(Constructed.) Roughly forty hours of cumulative rework, spread across fourteen months in increments small enough that no one ever saw the total.

And an unknown number aged out. Nobody can say how many, because rejected claims that were never resubmitted are not in any report — Chapter 24 §24.1's fifth row again.

What was actually required

The payer had changed a requirement, effective at a plan year, and had:

• Published it in its companion guide, which is on the provider portal
• Announced it in a provider newsletter
• Included it in a portal banner for some period

None of which anybody at the practice read.

(Constructed.) The requirement itself was mundane — a specific element the payer wanted populated in a defined way, one line in a table on page twelve of a forty-page PDF.

How it surfaced

Not through the rejections.

The practice was preparing for a contract renewal and someone was reviewing the payer's materials for an unrelated reason. She read the companion guide because it was in the folder.

Page twelve explained fourteen months of rejections in one sentence.

What it shows

First, the information was available the entire time and that is the whole point. This is not a case of a payer hiding a rule. The payer published it three ways. The practice did not read any of them, and "available" and "found" are different states.

Second, the oral tradition was worse than not knowing. "Put the ordering provider in even when there isn't one" worked two-thirds of the time, which is exactly the failure rate that prevents anyone from investigating. A workaround that never works gets escalated. A workaround that mostly works becomes institutional knowledge, and it is passed on to the next person as a fact.

Third, the rework was invisible because it was distributed. Forty hours in fourteen months is under forty minutes a week. Nothing about that shows up anywhere, and Chapter 24's Case Study 2 made the general version of this point about staffing.

Fourth, nobody escalated because the queue stayed current. A team keeping up with a problem prevents anyone from noticing the problem — which is uncomfortable, because keeping up is what they are asked to do, and it is the behavior that concealed this for over a year.

And fifth — the finding came from a contract renewal, again. Chapter 23's Case Study 2 was found by a due diligence team; Chapter 24's Case Study 2 by a contract negotiation. Three of this book's findings have now come from someone reading materials for a commercial purpose, and the pattern says something specific: the only time most organizations read a payer's documents is when money is being negotiated.

The lesson

A payer's companion guide answers questions your billing office is currently answering by trial and error.

Four carry-forwards:

Download the companion guide for each of your top payers. Once. It is a finite task — most practices have five or six payers that matter — and it is the single most concentrated source of "why does this payer reject what everyone else accepts."

Treat a rejection category as a category, not as a queue. The question is not how do I fix this claim; it is how many of these have there been, and what do they have in common? Chapter 29 §29.4's classification is what makes that askable.

Distrust a workaround that mostly works. A partial fix that nobody can explain is a symptom with a bandage on it, and the two-thirds success rate is precisely what stops the investigation.

And read the payer's materials when nothing is wrong. Not during a renewal. The renewal is when somebody happens to look, and this book has now recorded three findings that arrived that way — which is three more than arrived from anyone reading them on purpose.

Discussion questions

1. The payer published the requirement three ways. Is the practice's failure to find it reasonable? What would you expect a well-run billing office to have done?

2. The oral tradition worked two-thirds of the time. Explain precisely why that made things worse than a workaround that never worked.

3. The team kept the queue current and that concealed the problem. Is there any version of "keep up with the queue" that would have surfaced it? Design it.

4. Forty hours over fourteen months is under forty minutes a week. Name two other costs in this book that were invisible because they were distributed, and say what they have in common.

5. Three findings in this book came from someone reading payer materials during a commercial negotiation. What does that tell you about when organizations actually read things — and what, if anything, would change it?