How to Successfully Appeal Denied Claims

by | Published on Dec 14, 2018 | Medical Billing

Appeal Denied Claims
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Medical billing services are important for physician and healthcare practices since their bottom-line depends on these resource-consuming tasks. And these tasks are nothing short of challenging, which is why physician practices often come across situations when they have to deal with claims that have been denied.

Claim Denials Are Common

Denials aren’t rare at all. When it comes to employer health plans, one in seven claims is denied. Appealing denials is not always successful, with Medical Billing Advocates of America claiming there is only a 50-50 chance of successfully appealing denials. In many cases, errors in claims are responsible for denials. According to the American Medical Association, on average, 9.5% of health claims that private health insurers process contain errors.

You know you need to be genuinely paid for the care provided, and so you kick-start the appeal process. Now if you’ve done this recently you’ll know it isn’t as easy as it sounds. Insurance companies have tons of parameters that denied claim appeals need to fulfill, and if you don’t get it right your claim just won’t be processed at all. So how do you get this right? Well, when you outsource medical billing, much of the stress regarding reimbursement and denials are reduced. But if you, as a physician, or your in-house team is handling this, here are some factors you can take into account.

What You Can Do to Ensure Successful Appeals

Keeping in mind a few steps and following them to the book should help:

  • To appeal denials you must first be able to recognize them. Why is this hard? The insurance company declares that the amount for reimbursement is “$0”. Next to the amount paid, it would also enter the code for the adjustment reason. You need to figure out if this denial isn’t part of any contractual adjustment, because in that case it becomes a write off.
  • Along with identifying a denial, you need to figure out what the reason for the denial is. As we saw above, there is the reason code. Along with that you also have the remark code. You need to check up what the insurance company’s definition for that particular code is. That way you can understand what the possible reason for the denial is.
  • The remark codes are important, and are the main factors why the claim is denied. So make sure you address those specific points rather than submitting that same medical record again. Make sure there isn’t any information that is missing. Specific data in the form of reports is important proof of the validity of your claim. Every bit of documentation is essential. It helps make the case compelling.
  • As important as the specificity of the appeal claim is the procedure for the appeal. Insurance providers have a specific form to complete. Ensure that the correct form is filled. The CMS (Centers for Medicare and Medicaid Services), for example, has a form for appealing Medicare claim denials known as the Medicare Redetermination Request Form. Such protocols must be followed to increase chances of successful appeals. Also remember that there are many appeal levels. You can go through all of them, and even then if you haven’t got the desired outcome there is also a grievance process. It is important to never lose heart or give up.
  • Give the insurance company the idea that you are familiar with regulation. And this regulation is what you must use for your advantage as a valid point for appealing the denial. The Affordable Care Act (ACA) has grown its access to external reviews too. Aspects like these are not something insurance providers want healthcare providers or patients to know. By this rule, healthcare providers appealing on behalf of a patient can ask for an external review if all the internal reviews have been exhausted. For this, healthcare providers must obtain an authorization from patients to follow up appeals on their behalf. With external appeals being unbiased, the quality and fairness of claim review increases. There is also greater transparency regarding the insurance provider’s reasoning.
  • Also be aware of exceptions to insurance payer policies. Insurance payers do make exceptions in some cases. This is particularly true for diagnostic procedures involving x-rays, lab tests, etc. revealing some abnormal presentation for the patient. And there are certain clinical guidelines only applicable to patients of a certain age, such as adults and not pediatric patients. All these loopholes, exceptions and provisions must be used when applicable. Don’t leave any stone unturned.
  • Submitting the appeal isn’t the end of your efforts. You must call and confirm that the insurance company has received the appeal, or review the submission online. And then you need to follow it up in 30 days.
  • It’s helpful to maintain a record of all the denied claims you’ve had. You need to measure the data every quarter. What you need to do here is compare your reimbursement rate with your denial rate. A good rate of reimbursement is great, but you must also ensure your claim denial rate is less. You must work to get your denials down since that affects the bottom-line of your practice. Maintaining a record helps you to analyze how your contract with the insurance provider has contributed to your bottom-line.

Successful medical billing is important for your practice. While it can be a daunting task, the services of a professional medical billing and coding company can be really helpful here.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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