Providers are fighting to be reimbursed for every dollar. Getting reimbursed properly requires back office staffs to diligently pay attention to changes in payor rules.

Barriers to Proper Reimbursement

It is not unusual to hear horror stories from billers regarding denials by payors. Some private payors appear to deny all claims the first time they are submitted, even if the claims are documented correctly. Other problems may involve payors changing the rules so frequently that a service which pays one month may be denied in the next. Lastly, when billers attempt to resolve claim errors, insurance companies may be less than helpful, telling billers they “ought to know” what to do.

What Can Be Done

“A Dozen Steps to Successfully Appeal Denied Claims” on Codapedia, the free encyclopedia for Medical Reimbursement, makes the recommendation of auditing the insurance payor trends to see if they are consistent with the contract. If the practice got a “good deal” on the payment rate but the payor has provided a high denial rate, the difference in the payment rate and the amount actually paid after adjudicating claims may not be a very good deal after all. 

Some additional suggestions:

• Understand why the claim was denied. In some cases, the reason for denial is too generic for the provider to interpret, so practices resubmit claims repeatedly until they find the magic combination. Understand early.
• Follow the insurance company’s rules. Update your sticky notes or customizable code scrubbing software as often as insurance companies update their requirements.
• Make a compelling case. Use professional language and reference key publications, including copies of selected passages in your claim to support your case,
• Confirm receipt. Follow up on your claim submissions by calling and emailing the recipient.
• Set boundaries. Some claims may cost more to resubmit than you would receive.
• Compile appeals. Present multiple denials for consideration at the same time.
• Maintain a hassle folder for each company. Organize your denied claims by dollar and type.

The author is right by saying, “Preventing denied claims is a key skill of successful billers. But getting some denials will always be a fact of life in today's complicated physician payment system. Appealing denials is your right: it pays to exercise it.” Billers must fight for every dollar, but in many cases, the fight pays off.  

For information on customizable code scrubbing software that can decrease your practice’s denials, contact us.