Dealing with insurance denials

One of the most difficult jobs in the medical office for the billing department is handling insurance denials. Unfortunately, many claims are rejected for various reasons, and if they are 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 resolve these issues. If your office doesn’t have the time and resources to take care of these denials, your progress will suffer.

Denials can range from no coverage to treatment notes needed. Each individual refusal must be investigated to determine how you will be paid for that date of service. Often it only takes a phone call to solve the problem, but that phone call can take up to 45 minutes to achieve the desired result. Some denials require the claim to be resubmitted. An incorrect diagnosis code is an example of this. Some denials will result in the patient being billed for the service, but it may still take a 30 minute phone call to make sure you’re doing the right thing.

The secret to effectively handling denials is to respond to the denials as quickly as possible. Many denials have a time frame that must be met. Then you need a good system to deal with the refusal. When a claim gets rejected, find what works best for that issue and use the same method every time you get that denial. Find the most effective solution for each refusal and use that solution as soon as you receive the refusal.

For example, if we get a refusal for medical records or treatment notes, we immediately type a note and fax it to the provider’s office to let them know we need the records. We then put the refusal in the front cover of the folder intended for that provider. Once the notes are sent to us, we go to the provider’s directory and retrieve the refusal. We print a new claim form and attach a copy of the rejection and notes and note on the computer that the records were sent with that claim.

Sometimes denials are completely false. Usually a phone call to the insurance company can solve the problem. We have sometimes rejected claims in the editing stage of an electronic submission without insurance coverage. A phone call to the insurance company or sometimes checking their website can tell us that the identification number prefix has been changed. We change the prefix and resubmit the claim. Or maybe we made a typo in the ID# that needs to be corrected.

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We’ve had claims that were accepted but applied to the deductible. After the patient was billed, we got a call from the patient saying they either don’t have a deductible or it has already been met. Sometimes the patient is wrong and sometimes the insurance company is wrong, but all of these challenges must be addressed if you are to receive compensation. The longer you wait to resolve the issues, the more likely you are not to be paid.