I have received claims denials, now what?

Set aside a specific amount of time to work the denials received. The practice will be better off for this approach, because consistent data entry problems or billing errors can begin to show a pattern in poor workflow or training needs. Insurance companies also have time limits on adjusting and reviewing appealed claims, so time is of the essence.

When we receive a denial on a claim, we can use a logical approach to resolve the problem. Here are a few common reasons for denials and the steps toward resolution:

Eligibility or Coordination of Benefits–locate a copy of the patient’s insurance card and compare it carefully to the information coded in the system. Make sure data entry has been performed correctly for patient demographics including the spelling of name(s), birth date, etc. Compare the eligibility dates with the dates of service being billed. Check the insurer’s eligibility information by contacting the insurance company online or by phone. If you cannot resolve the problem, call the patient and ask them what information they have received from the insurance company regarding the denial. Sometimes the patient has the responsibility to clear up the issue.

Timely Filing – make sure the claim reflects the correct date of service. Call the insurance company and ask what the timely filing rules are for your practice (rules vary by state and contract). If everything is verified as correct, ask the insurance company to adjust the claim. They may ask for a timely filing report. If it was a paper claim, ask the insurance company if they accept a screen shot of when the claim was filed for proof.  Your billing system should be able to produce an EDI document of timely filing if you bill electronically. If there were extenuating circumstances that resulted in late filing, resubmit the claim with an appeal asking for leniency.

Bundling– check to confirm if billing was done correctly. Check NCCI (National Correct Coding Initiative) edits to see if another procedure was billed on the same day that superseded or included the procedure being denied.  Check also for whether a modifier should (or should not) have been added. Decide if the claim should be billed as a correction, appealed for special circumstances, or accepted as bundled.

Medical Necessity– insurance companies have system edits that alert staff to the necessity of further review. Many ICD 9, CPT, and HCPCS codes are programmed to stop during processing to allow review of the claim by the insurer’s staff. Some codes may automatically reject.  Make sure the billing submitted is correct, including the diagnosis. If necessary, correct the claim and re-bill according to that insurance company’s rules on corrected billing. If the insurance company is asking for medical records, send all documents asked for; especially anything that supports the decision to provide the treatment. Act on this as soon as possible, because most appeals take up to 60 days.

Not a benefit– as always, make sure the diagnosis and procedure codes are billed correctly. If the insurance company has ruled a service as not medically necessary, there is no benefit available to anyone under their membership. If an individual policy does not offer the benefit (such as maternity, elective surgery, etc.) then the patient’s specific policy is the determining factor. Either way, the service will not be paid. Review previously billed services to detect any errors on the insurance company’s part. If it was a benefit last week, it should be acceptable this week. Call the insurance company for an adjustment to their error. If a call or online review reveals the patient does not have coverage for that service, accept the denial and make a note for the future. Be sure to alert the physician and staff as well to prevent future denials.

Duplicate-review  the patient’s charges to identify a duplicate billing, previous payment, or if the claim has been submitted more than once. Pay attention to professional, technical, and global fees for the same code.  Look for any other diagnosis that the patient could have been billed under. If there is nothing to indicate a similar charge was billed, check the insurance company records to see what they have that could be bumping against the service. Perhaps they just paid on another claim and the denial reached the office before the check did. If you cannot find a duplicate, ask an insurance representative to check other providers on the same date. If nothing can be resolved, ask the representative to prove that the charge is a duplicate by researching further and either adjusting the service to pay, or sending a letter in writing explaining why the service cannot be paid.

It is easy to make mistakes in data entry and billing, even when we are taking great care. Sometimes there are many different elements in decision making, or possibly several people are entering data on the same chart. Once a claim has been sent, it has moved on to other systems outside of our control with the potential for additional mistakes in data entry or guidelines.  Being diligent in following up on claim denials can teach us a lot about best practices in our own office.