Medical Billing is as Tough as Keeping Score in Tennis-Part 1

I happened across Wimbledon tennis on the television.  It reminded me of the brief time in my past that I attempted to learn to play tennis.  When learning any new sport, there are the physical lessons that we are taught as well as the rules of the sport.  Most often those physical lessons are relatively easy to grasp, but less than easy to perfect.  The basic rules are usually the opposite, but I admit, I was more than slightly perplexed at the scoring system in tennis.     

Love Equals Zero

For those unfamiliar, I will let Wikipedia explain: “… scores from zero to three points are described as "love", "fifteen", "thirty", and "forty" respectively.”

Okay, really,points 0 to 3 are not just 0 to 3? 

Also, 1 and 2 are worth “15” but 3 is only worth “10”? 

Who came up with that logic? 

The unusual scoring methods don’t stop there, but I think I have made my point.

Well part of my point. 

In tennis, in life and in the world of medical billing, we are constantly faced with situations that may seem illogical or over complex without reason, but we must learn to accept them, and develop strategies to cope.


Point One (or Fifteen in Tennis)

“Referral required”:  The term referral in the medical world has two related but definitely distinct meanings.

In the good old days, a physician referral was when the current provider “recommended” you see a specific colleague for your condition. 

Dr. Kildare would say “Mrs. Jones, I believe you should see a dermatologist for that suspicious area.  I would like to contact Dr. Welby over on Main Street.  The nurse will give you his number.” 

Tada, Mrs. Jones would call Dr. Welby’s office, go in and have her issue addressed.

Then insurance plans developed the Managed Care model and that term referral was used to indicate the need for a written order by the primary care provider or the insurance company that granted permission for the patient to see a specialist.

Unfortunately in those early Managed Care days and even today with new enrollees, patients assume the “verbal” referral from Dr. Kildare to see Dr. Welby is what the insurance means by referral.

The typical conversation goes something like an Abbott and Costello routine:


Staff: “Welcome to Dr. Welby’s office. May I have your referral please Mrs. Jones?”

Mrs. Jones: “Dr. Kildare referred me.”

Staff:  “I see.  Is Dr. Kildare your primary care physician?”

Mrs. Jones: “Yes and he told me to see Dr. Welby.”

Staff: “Did you bring your referral?”

Mrs. Jones:  “I told you Dr. Kildare referred me to Dr. Welby.”

Staff:  “I understand, but your insurance company requires a referral for your visit?”

Mrs. Jones:  “What does my insurance have to do with it?  My doctor referred me here.”

Eliminate these types of frustrating encounters by getting complete patient insurance coverage information as soon as the appointment is made.  Once you know a referral is necessary, notify the patient immediately to explain the situation. You may still have the above conversation, but it won’t be at your front desk with a waiting room full of patients.  You can even go right to the source and contact the primary care physician’s office to cut down on the turn-around time to receive the appropriate referral.


You can use the Real Time Eligibility function in Iridium Suite Practice Management Software to quickly and easily

verify insurance coverage information on patients prior to visits.


Another way we often feel like are hands are tied is when we encounter the pre-authrozation requirements and processes enforced by the growing number of managed care plans. 

We have become well aware that any procedure considered to be of a significant cmplexity level(cost) needs to have authorization obtained per the payer’s protocols.

Some payers have even realized the effort to review the requests is so extensive that they have  contracted out to third party utilization companies like MedSolutions, Availity, and Coresource. 

“Routine” requests are often relatively quick, but I you can encounter hurdles when the provider is ordering a procedure that does not  fall into the  predetermined scenario set by the payer.  These predetermined utilization standards are based upon the “common” accepted medical guidelines. 

Billers know though that we do occassionally have a patient that has one of the “special circumstances.”  This is when we “go to battle”.

A handy tool found in Iridium Suite Billing Software is the ability to indicate when a payer requires authorization for services.  When the user has this indicated on a patient account, all charges added are  “scrubbed” against that requirement and the system will notify the user when the authrization is missing. 

This eliminates payer denials and increases your chances of quick and proper claims reimbursement.

Thank you for following along for part one of the common trials and tribulations in medical billing.

I hope this provided insight, entertainment or a feeling of not being alone in your struggles.

As the great tennis of Wimbledon continues, keep an eye on your inbox for Point Two (or Thirty in Tennis).