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 for that service. Most offices are extremely busy and it can be difficult to find the time to deal with these issues. If your office doesn’t have the time and resources to handle these denials, your accounts receivable will suffer greatly.
Denials can range from no coverage to necessary treatment notes. Each individual denial must be analyzed to determine how you will be paid for that date of service. Many times it will only take a phone call to fix the problem, but that phone call can take up to 45 minutes to achieve the desired result. Some denials will mean the new presentation of the claim. An incorrect diagnostic code is an example of this. Some denials will result in the patient being billed for service, but it may still take a 30 minute phone call to make sure he is doing the right thing.
The secret to handling denials effectively is to act on the denial as soon as possible. Many denials have a time frame that must be met. So you need a good system to deal with 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 for each denial and use that solution as soon as you receive the denial.
For example, when we receive a denial for medical records or treatment notes, we immediately write a note and fax it to the provider’s office letting them know we need the records. We then place 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 a new claim form and attach a copy of the denial and notes and note on the computer that the records were submitted with that claim.
Sometimes the negations are completely wrong. Usually a phone call to the insurance company can solve the problem. We sometimes have claims rejected at the editing stage of an e-filing for not having insurance coverage. A call to the insurance company or sometimes checking their website can tell us that the ID number prefix has changed. We change the prefix and resubmit the claim. Or we may have made a typographical error in the identification number 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 saying that he did not have a deductible or that it had already been met. Sometimes the patient is wrong and sometimes the insurance company is wrong, but all of these challenges must be addressed if he wants to get paid. The longer you take to resolve issues, the greater the chance that you won’t get paid.