Have you ever been in a situation where you are expecting your insurance claim amount to be cleared and you get a denial in return? Having medical insurance denial is a common scenario. Even healthcare service industry experts who take adequate precautions to prevent pitfalls in insurance claims, get stuck in claim denials. It can be a complicated, time-consuming, and frustrating process when your medical insurance claim is rejected. The scenario is complicated for both administrative staff of medical billing management as well as practicing physicians.
If you have ever been in a situation of claim denial or want to avoid it. Then you should learn about basic strategies regarding the solution of claim denials. That can save a lot of time for practitioners and improve their cash flow too. Here we list for you the most effective pointers that will help you to handle claim denials:
Review all the notifications concerning the claim carefully
It may seem obvious but it is one of the crucial steps in processing claims by medical billing service providers. When you are getting remittance advice, or other notification or explanation of benefits provided by an insurance company with regards to a claim, then you should check it carefully.
The notification that the insurance company has sent should mention clearly whether the claim you had made was delayed, paid in full, denied, or partially paid. If the company has declared the claim to be unclean. Then you should work according to the carrier’s instructions regarding submitting your claim along with any corrected or missing information.
If the company has paid your claim partially or denied it then the notification would mention the reasons for it and mention the particular procedures and also documentation that needed to resubmit the claim or if you want to file an appeal. On the other hand, if the notification that you received is not clear. Then you should call the insurance company to provide more information.
They will let you know about the reason for which the claim denied and you will also find out that there was incorrect adjudication of the claim. Because of any type of administrative error that was made by the payer. You can also get information about the submission procedures of the claim. If they do not match the requirements of the company. You can make some basic adjustments to the submission procedures to make your future claims submitted in a streamlined manner.
If the claim you have resubmitted is denied and you feel that the denial was not proper. Then you can have the decision appealed to the guidelines of the insurance company. You should first collect all the needed information for submitting the appeal.
The procedure for appeal usually varies according to state law and the insurance company. In general, the appeal should include a reason for request of your reconsideration and you should attach supporting documents along with it such as a claim’s copy. That you are resubmitting, and a copy of any communication you had with the company earlier regarding this matter.
If the claim is denied for the reason of medical necessity then you would have to submit more information to show the necessity. It is important to meet the obligations according to the HIPAA i.e. Health insurance Portability and Accountability Act to protect notes of psychotherapy and to give only the extremely necessary information.
In this case, you would have to resubmit the claim or make an appeal multiple times to change the decision of the company. You should not give up. With your persistence, you can show the insurance company that you are determined to resolve the problem and want to get paid.
Do not Delay
You should submit claims multiple times but in a timely fashion within the specified timeframe of the company or according to the laws applicable in your state. Else the claim would be adjudicated according to the information that you provided previously. The company can deny your requests of appeal or reconsideration as untimely.
Know About the Process of Appeals
If you are submitting an appeal then you should know about the process of the company’s appeal. If you are aware of the policies then you can respond to the company’s actions in a better manner. Have updated information about the adjudication of claims and the process of appeal regarding the insurance company with whom you work.
You can get this information on the carrier website. These companies also provide hard copies regarding this when a new contract signed with them.
Maintain Disputed Claims Records
When you get in touch with an insurance company to get more information regarding a claim. Then you should keep a record of all details that provided to you along with the complete name of the person with whom you speak. This information stored along with other important information of the claim including why partial payment of the claim was done, or why it was denied or delayed, the outcome, and the actions that the office had taken for the claim’s follow-up.
These records play an important role in actions that taken in the future. Such as taking the appeals to a higher level by submitting complaints to the insurance commissioner at the state level or pursuing any litigation subsequently. The records would serve as a useful file of appeals letters as samples and documentation. That can help your office in resolving or avoiding future denials of claims.
Be Ensured That Help Would be Available
While it can be a frustrating process to handle claim denials, in the long run it can benefit you by saving money and time. They would alert you about the requirements and expectations of the insurance carrier with whom you have the contract. You should ensure that your medical billing service providers are consistent with the requirements of the company. So that you can reduce the chances of denials and rejections in the future.
These are the top effective ways to fix claim denials. If you are a healthcare provider and want claim denials to be fixed, contact Unify Healthcare Services today. We are HIPAA and ISO certified medical billing experts to help you get through the process of claim denials smoothly.