Question

An out-of-network provider calls and tells you he wants you to readjust a recent claim so he can receive more money. He is very pushy and angry because he believes he deserves more money than what was paid. What should you do?

1) Agree to readjust the claim as requested
2) Explain the payment process and why the claim was paid as it was
3) Offer to review the claim and provide additional information if necessary
4) Transfer the call to a supervisor for further assistance

Answer 1

Explain the payment process and offer to review the claim with the out-of-network provider. Do not adjust the claim without proper review. If necessary, transfer to a supervisor for additional support.

Step-by-step explanation:

When an out-of-network provider calls to ask for a claim to be readjusted with the aim of receiving more money, as a professional, you should not agree to readjust the claim as requested without proper verification. Instead, option 2 and option 3 from your list are both appropriate responses. You should explain the payment process and the reasons why the claim was paid the way it was, which provides transparency. Additionally, you can offer to review the claim and provide additional information if necessary, ensuring that all claims are handled fairly and according to policy procedures.

If after these steps the provider is still not satisfied, you can transfer the call to a supervisor for further assistance as per option 4. It's important to handle such situations with professionalism, reiterating the company’s policies, and being open to investigation without making any immediate commitments to adjust the payment.