Handle Improper Denied Claims

Insurance denials are inevitable for any Physician Office. What can Providers do to minimize the prevalence of specific types of insurance denials?
1. Verify insurance benefits for upcoming appointments
2. Make sure the Provider is eligible to be reimbursed by insurance carrier for procedure
3. Check your Place of Service (Inpatient/Outpatient/ASC)
4. Do not bill for Bundled Services
5. Authorize for Service prior to treatment
6. Perform Medically Necessary Services
7. File claims On Time

8. Assign appropriate Modifiers
These above steps can trim down the number of denials your Practice may receive. In contrast, there are various insurance delays that your Practice will encounter that will be unavoidable.
Specifically:
1. Pre-existing review
2. Medical Records Review
3. Accident Details
These are a few of unavoidable delays for reimbursement. What can you do to arm your Practice to be equipped to respond to these delays in payment?
1. Hire skilled Accounts Receivable staff
2. Have all Supporting medical records available to forward to Medical Review department of insurance carrier in regards to the specific claim in question.
3. Obtain relevant information from patient regarding any sustained injury, so this can be appropriately documented for the patient medical record; and available to forward to insurance carrier.
These are a few ways to successfully manage denials. In doing some of the listed items, you can significantly reduce the number of improper denials sent to your Practice.
Improper Insurance Denials
Even despite our best efforts, frustration can set in when claims are inappropriately denied by insurance. Appealing claims is the call of duty for most practices, hospitals and ambulatory surgical centers. What are the elements of a good appeal? How should a good appeal begin?
A thorough assessment of the denial reason the insurance carrier has provided should be the first step. Next, if the denied reason can be addressed over the phone, this is the best way to begin. However, in many cases, these types of denials will require a written appeal. If the denial is related to medical necessity, begin by carefully reviewing the insurance carrier's Medical Policy. Next, examine the medical record to ensure the procedure or service performed is compliant with the carrier's medical policy. After that is established, begin writing your appeal. Start by stating the purpose of your letter. Next, state the reason (provided by the insurance carriers EOB) the claim was denied. Then, state the reason(s) the denial is incorrect (reasons identified when medical record and medical policy was inspected) and why the claim should be reconsidered for reimbursement. Lastly, express that you would appreciate this appeal being handled in an expeditious manner.