Dealing With Insurance Denials

One of the most difficult tasks in the medical office for the billing department is dealing with insurance denials. Unfortunately many claims are denied for a variety of reasons and if not handled properly no payment will ever be made on that service. Most offices are extremely busy and it can be difficult to find the time to take care of these problems. If your office does not have the time and resources to take care of these denials, your receivables will greatly suffer.

Denials can range from no coverage to treatment notes needed. Each individual denial needs to be looked into to determine how you will get paid for that date of service. Many times it will take only a phone call to fix the problem, but that phone call can take as long as 45 minutes to accomplish the preferred outcome. Some denials will entail the resubmission of the claim. An incorrect diagnosis code is an example of this. Some denials will result in billing the patient for the service but it may still take a 30 minute phone call to be sure that you are doing the right thing.

The secret to handling denials effectively is to act as soon as possible on the denial. Many denials have a time frame that must be adhered to. Then, you need a good system in place for dealing with the denial. When a claim is denied find what works best for that problem and use the same method each time you get that denial. Find the most effective solution to each denial and use that solution as soon as you receive the denial.

For instance, when we get a denial for medical records or treatment notes, we immediately type up a note and fax it to the providers office to let them know that we need the records. We then put the denial in the front flap of the folder designated for that provider. As soon as the notes are sent to us we go to the provider’s folder and retrieve the denial. We print out a new claim form and attach a copy of the denial and the notes and note the computer that the records were sent with that claim.

Sometimes denials are completely incorrect. Usually a phone call to the insurance company can resolve the problem. We sometimes have claims rejected at the edit stage of an electronic submission for no insurance coverage. A call to the insurance company or sometimes checking their website may tell us that the prefix of the identification number has changed. We change the prefix and resubmit the claim. Or we may have made a typo in the ID# that needs to be corrected.

We have had claims that were accepted, but applied to the deductible. After the patient was billed we received a call from the patient stating that they either don’t have a deductible or that it has already been met. Sometimes the patient is wrong and sometimes the insurance company is wrong, but all these challenges must be dealt with if you are to receive payment. The more you delay in dealing with the problems, the better the chances are that you will not be paid.