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Working Your Denials – Don’t take No for an Answer!

3rd Party Billing and Collections
Yvette Noel
in 3rd Party Billing and Collections
By Yvette Noel CPCO

Claim denials cost the medical community over $1 million annually

How much are you contributing to that amount? We all know how hard it is to keep up with insurance verifications, scheduling patients, answering the calls…etc. Those are the daily events we must attend to in order to have a claim to follow up on, but are you following up or leaving money on the table?

If you have your processes in place, you are keenly aware when a claim has not been paid and the reason why. You have even taken the time to appeal it, call the payer, appeal again and call again, but the circus continues, and the merry go round keeps going around.

  • Did you know that there is a third level of appeal that doesn’t involve a judge or arbitration? Let’s talk a little more about that by laying some initial ground work. First start by asking these crucial questions.
  • Did the staff verify the benefits?
  • Do you have a copy of the payers Medical Review Policy for the services rendered?
  • Did you obtain the necessary authorizations for treatment? Did you remember to add the code to the claim form?
  • Did you code correctly?
  • Did you submit the claim within the payers timely filling rules? (Yes, there are rules on how long you can wait from the time of service rendered to submitting the bill.)

If all is good with the above, put your thinking cap on and go to work. At this time, start the process for reconsideration or first-level appeals. Make sure to include the necessary documentation for the payer to reconsider the claim. If this visit is a mid-treatment plan, you may need to send more than just the notes of the date of service in question.

Second level appeals

If the service is denied again, and you are confident it is a covered service, move forward to a second level appeal. Be sure to reference items like CPT guidelines for a specific service and the payer’s Medical Review Policy. This time mail the appeal to the address you received on the first-level appeal denial letter. Be aware that this step may take a little longer, but don’t let it fall off your radar.

Let’s say you get another denial. Don’t be tempted to give in and miss out on appropriate revenue. Even though the payer may say you have exhausted your rights to appeal, if you know it is correct, don’t give up. Take it up the food chain! Something we should know, but don’t think to do, is email the payer’s CEO. I have used this option regarding orthotics non-payment in West Virginia and was successful in seeing wrongful decisions overturned for not just our offices, but other offices within our state.

You ask, how do you get an audience with the CEO? Well, for me it was quite simple. We just happened to be at a function together, and I took advantage of that opportunity. While it is not everyday that you are at an event with the payer’s CEO, there is often executive email addresses on the company’s website.

One more opportunity in your arsenal is to find out if your state insurance commissioner has jurisdiction over the payer in question. The insurance company does not like being contacted from the commissioner. You can also research ERISA to see if there is assistance with the payer.

As a KMCU member, you can find more on this topic in our Billing and Collections Department. Not a member yet!? Click HERE for a no-obligation demonstration of the most comprehensive training tool in the profession, the KMC University Library!

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