Documenting a Follow-Up Call

A call is a way to get an answer that no automated channel will give — usually because the question is about something specific enough that no standard transaction carries it. That is genuinely valuable. What it is not is a decision. A representative saying a claim “is being reprocessed” has not reprocessed it, cannot be held to it, and in most cases has no authority to commit the payer to anything.

The corpus states that rule for the appeal case — a phone assurance that an appeal is pending or even approved is not the decision — and it generalizes. A decision that moves money exists when it is on a remittance or in a written notice. Everything before that is information, and information decays unless it is written down.

Date and time

Not for tidiness. Filing and appeal windows are counted, so a call near a boundary is either evidence or nothing depending on whether the date is recorded. Record the time as well where a payer's own day-boundary matters.

The payer's call reference number

The most valuable field on the list, because it is the only one that gives the practice leverage over the payer's own record. Ask for it before the call ends. If none is offered, ask again — and if there genuinely is none, write down that none was given, which is itself a fact about the payer worth having.

Who you spoke to

A first name and whatever identifier the representative offers. A call attributed to nobody is much harder to reconstruct, and the difference in effort at the time is a few seconds.

What you asked, as they heard it

The claim as identified to them — which claim, which dates, which member. Half of all disagreements about what a payer said are really disagreements about which claim was being discussed.

What they said, in their words

Recorded separately from what you concluded from it. This is the discipline that distinguishes a usable note from a useless one: “rep said the claim is in review, no additional documentation needed” can be re-examined; “claim is fine” cannot.

What was promised, and by when

Any commitment, with the date it should land — and the consequence if it does not. A promise with no date attached is not something anyone can follow up on.

The next action and its date

The field that stops the call from being a way of making the account look worked. A contact that ends without one has advanced the claim's age and nothing else.

Before dialing, it is worth knowing which kind of call this is, because the answer changes what should be recorded and what should be protected in the meantime.

Medicare draws a distinction that is useful well beyond Medicare. A reopening is, in the words of 42 CFR 405.980(a)(1) (opens in a new tab), “a remedial action taken to change a binding determination or decision that resulted in either an overpayment or underpayment.” It is a route for correcting something — including, expressly, a clerical error — and it is not an appeal. The two run on different tracks with different timeframes.

The reopening timeframes are not reproduced here. They are Medicare's, they differ by the basis being relied on — routine, good cause, clerical error, fraud — and a reader applying them to a commercial payer would be applying somebody else's rule. What travels is the shape: some things are corrected and some are appealed, the routes are different, and using the wrong one spends a window on a process that was never going to produce the outcome.

• A call that can fix. Where the issue is a demonstrable error rather than a disagreement about coverage or judgment. Record what correction was requested, on what basis, and what reference the request was given.
• A call that can only ask. Where the issue is what the payer decided. The call gathers information; the remedy is elsewhere and is on a clock. Record the information, and make the next action the one that protects the clock.

A conversation about a claim is a conversation about a patient, and practices tend to think about identity verification only for calls with patients or their representatives. The obligation is stated more broadly than that.

Under 45 CFR 164.514(h) (opens in a new tab), prior to a disclosure permitted by the rule, a covered entity must verify the identity of a person requesting protected health information and that person's authority to have access to it, where the identity or authority is not already known — and must obtain any documentation, statements or representations, oral or written, that the rule makes a condition of the disclosure.

A note that exists somewhere other than the account is a note that will not be found by the person who needs it. That sounds obvious and is routinely violated, usually by a spreadsheet that one team keeps because the account note field is awkward.

• On the account, not beside it. The test is whether someone opening the claim cold sees the call without knowing to look elsewhere.
• Structured enough to be counted. Free text is fine for what was said; the date, the reference and the next action should be fields, or the practice can never answer how much of the book has actually been contacted.
• Attached to the claim the call was about. A note on the patient rather than the claim is unfindable at the moment it matters, particularly where a patient has several open claims.
• Durable beyond the person. The whole point is that the next person does not have to call again. A record only its author can interpret has failed at its third job.

• “Called payer, pending.” The commonest note in any billing system, and it contains nothing: no reference, no name, no statement, no next action. It records that time was spent.
• No reference number. Asked for at the end of the call or not at all. Without it the practice has an account of a conversation the payer cannot locate.
• Conclusion recorded instead of statement. “They said it was fine” cannot be re-examined when it turns out not to have been.
• A promise with no date. Nothing to follow up on, and no way to tell whether the payer did what it said.
• The correction route mistaken for the remedy. A request to fix something was made, felt like progress, and the appeal window kept running — and where the request is refused, that refusal may not itself be appealable.