In recent months, our experts have witnessed a significant increase in claim denial rate of our prospective and existing clients. Insurance carriers have taken up a tendency of denying payment for services for no medical necessity. Surprisingly, even regular office visits have been affected. In addition, there has been an increasing number of new benefit plans across the country. This has caused many eligibility-related denials. It is no secret that most claim denials are caused by the misconduct of insurance payers. So how do we deal with them?
Reversing a claim denial – WCH way
Once you get your “letter of fortune” (an EOB with a claim denial) – show it to your billing specialist regardless of the denial reason. Now, your primary concern is to figure out whether a denial is justified. No one is immune against mistakes, so you may get one of the following claim denials or underpayments:
• Lack of medical necessity
• Bundled procedures
• Inactive/invalid/incomplete coverage on the date of service
• Services rendered out-of-network are not covered by the plan
Denials related to medical necessity can be resolved if you swiftly submit the requested medical records to the insurance. All other cases, however, require to be investigated before you “give up” on them and/or bill your patient. Here is a step-by-step guide on how to deal with such claim denials:
I. Read the denial reason carefully and check its validity with your billing specialist
Is your claim denied for bundled procedures? See the CMS guidelines and check whether this denial is correct.
Is the reason related to eligibility? Get in touch with the patient and the insurance, check the dates and specifics.
II. Call the customer service or submit a reconsideration inquiry online
Once you have determined that a claim denial is contrary to a federal/local/commercial payment policy – contact the payer. Submitting a request for review online is the easiest, quickest, and safest way to do it. If you do not have access to the payer’s provider portal – call the customer service and ask them to send the claim for reconsideration. Do not forget to obtain a reference number for you to follow up on the inquiry later on.
III. Submit a first-level internal appeal
If a reconsideration inquiry did not bring any results, sending an official letter to the insurance payer is your next step. Make sure to list all the valid aspects in favor of your argument, and attach the proof or reference, if applicable. It may take up to 60 days for payers to process your appeal.
IV. Submit a second-level internal appeal
It is no time to give up even if your appeal upholds the original decision. Some payers offer an option to submit another appeal that would be reviewed by a team of certified medical professionals and/or billers/coders. We recommend that you send this appeal by certified mail, and follow up on its outcome with the customer service in about 3 weeks since the submission date.
V. Send an inquiry to your local Department of Financial Services or to a Department of Insurances
If the payer still fails to acknowledge the mistake, while you are still convinced of misconduct, please feel free to send an appeal to a local agency supervising commercial insurance payers. In New York, it is the Department of Financial Services (note: you need to register and provide practice-related information to utilize this tool). Once you submit an inquiry, relax and forget about it for a while since the resolution process make take up to 1 year to be completed.
By following these five simple steps, you will be able to overturn the majority of incorrect denials. But why would you do that on your own?
Minimize your claim denials and trust the resolution process to the professionals – try WCH. With over 21 years of experience in the industry, we know all the pros, cons, ups, downs, and pitfalls of medical billing.