Getting reimbursed for services rendered should be the least of worries for a healthcare provider. Unfortunately, claims are denied often and for various reasons.
Luckily, providers can get insurance payers to reverse their decisions. Under the affordable care act, providers have the right to appeal denied and get 6 months to appeal any denials. Insurance companies too are required to declare the reasons for denied claims.
Denial management is important for effective revenue cycle management. Working with a good billing company can make the process even faster and make managing appeals on denied claims easier.
As a healthcare service provider, If you have been wondering about reasons for repeated claim denials, probably this is what you need to catch up on. By following these tips, providers can ensure that chances of a successful appeal are maximized.
Understanding the reason for denial
The very first step in filing an appeal to the insurance is interpreting the reason for the denial. When insurance sends the EOB, it mentions every detail about the claim decision.
The codes mentioned in an EOB reflect the specific reason for denial. A key for codes is also provided so you can accurately interpret the reason for denial. If you are still not clear about the reason for the denial, you can contact the payer directly. Every medical provider in the US has the right to obtain the information in detail and payers are bound to explain that in terms that a provider can understand.
Eliminating Easy problems first
There can be several reasons for claim denials. One of the most common is a data entry error. It can be in the form of misspelled names, incorrect insurance policy numbers, different dates of service, etc. Make sure to read through the documentation provided to you from the insurance company and then look for errors. If any, you can request the insurance company representative to correct the same. If the error was from your side, you can simply modify the details and resubmit the claim.
Offering services that are not required is another reason for unwanted denials. Make sure you have the evidence and documentation to support the treatment or services you are giving, so in the end, you do not need to prove their medical necessity. Referrals, doctor prescriptions and any other information about the patient’s medical history can help your claim get approved. If needed, you may also want to consider the reference to the health plan’s policy or guideline for the services you are billing. The same is available online through their website.
Submitting the right documents
You may also be required to write a detailed letter to the insurance company. If you do, make sure to include the claim number and the member ID of the patient on it. Often, insurance companies process claims submitted with their standard appeals form faster. The EOB that you may have received can also tell you about the procedure you need to follow for the appeal process. If not, you can always call payer helplines and ask for the same.
Insurance companies have their own systems in place for tracing medical claims and subsequent appeals. The only thing you need to take care of is to be just as organized to make sure you’re following up on the details that might make a difference.
Consider keeping the paperwork at one single place and take notes during every phone call with the insurance company. You can ask for the names and job titles of the person you talk to and note that down with the date of your conversation, a reference number and any further steps you need to take. If you get to know that an appeal was forwarded or the claim was sent for a review, make sure to ask for a “Document Image Number” as well. This will help build your case and ensure that the next agent you talk to can quickly access the files and take the process further.
Taking it to the next level
Conventionally, medical providers used to appeal for the decision directly with the insurance companies. But, if the claim gets denied the second time, they may have one more chance to change their minds. The AFA (Affordable Care Act) by Medicare requires states to set up an external review process for denied medical claims. You can also check the CMS website for further reference and check whether the same has been implemented in the patient’s jurisdiction or not.
Speeding things up
If a patient needs medical care urgently, you may not want to wait for the insurance company’s appeal process to complete its course. You can also file an expedited appeal if the timeline for the standard appeals process jeopardizes the patient’s life or his ability to regain maximum function. Therefore, it is wise to file external and internal appeals simultaneously.