How Athelas Fights Insurers on Behalf of Healthcare Providers

How Athelas Fights Insurers on Behalf of Healthcare Providers

Athelas Team
Athelas Team
July 11, 2023

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Navigating the vast, turbulent waters of the healthcare system can be akin to steering a ship through a storm. Many small and medium healthcare practices often find themselves in this exact situation, struggling to keep their vessels afloat. That's where Athelas steps in - utilizing its generative AI-powered infrastructure for medical billing, as well as decades of collective experience dealing with the healthcare billing landscape, to help these practices weather the storm. Let's dive into a recent incident where Athelas successfully steered its clients through a particularly formidable challenge.

To fully appreciate the role Athelas played, it's crucial to understand Electronic Data Interchange (EDI) and Electronic Remittance Advice (ERA). These are vital lifelines for healthcare providers. EDI allows practices to submit claims electronically to insurance companies, speeding up the billing process and reducing errors. On the other hand, ERA is an electronic version of a payment explanation, providing details about the payments made by insurers against the claims.

Amid a wave of internal disruption and reorganization, an insurance company (who we'll keep anonymous) either intentionally or negligently stopped responding to Electronic Data Interchange (EDI) and Electronic Remittance Advice (ERA) submission requests by new billers for healthcare practices. This essentially meant that even though the doctors were part of the insurer's network, they were unable to submit any new claims after changing their billing companies. There was no way to tell what was wrong, and the payer refused to even respond to their pleas. For these healthcare providers, their livelihoods were at risk due to this problematic behavior.

This case, a blatant violation of the insurer's contractual obligations, could have severely impacted the doctors. The affected healthcare practices, being small and medium-sized, were unprepared to deal with this situation. More often than not, they lack sufficient cash-on-hand to make payroll if they’re left without claim reimbursement for an extended period of time. Limited by a lack of transparency and knowledge regarding the intricate mechanisms of healthcare billing, they were at a loss on how to get their claims approved. They also lacked the time and resources to fight this battle with the insurance company.

Enter Athelas. As a major force in the healthcare services sector, Athelas had the resources, knowledge, and the leverage to act on behalf of the affected providers. Given that Athelas represents hundreds of provider groups, its voice in this battle was much louder and harder to ignore.

After assessing the situation, Athelas took swift action. Our legal department, through a deluge of strategically crafted demand letters, cajoled the insurance company to prioritize the EDI and ERA requests from our clients. In less than a week, approvals were received, enabling hundreds of doctors to submit millions of dollars in claims as they should have been able to from the start.

This incident is just one example of the kind of support Athelas provides to its clients, ensuring that their rights are protected, their practices can thrive, and most importantly, that they can focus on what matters the most – providing quality healthcare. 

At Athelas, we are not just introducing next-generation technology and AI to Revenue Cycle Management (RCM). We are also the invisible protectors, fighting tooth and nail to ensure our doctors get paid what they deserve. We see the hurdles before our providers do, and take proactive measures to overcome them. Because at the end of the day, Athelas is more than a service provider; we are a partner, an advocate, and a guardian for our healthcare providers.