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Appealing a claim- Will a standard format work to improve your practice’s medical billing?

June 14, 2012

The procedure of appealing an insurance claim is intricate, although it can be successful if completed properly because there are many grounds for claims to be denied by an insurance company or a payer. The payer collects a lot of claims on a daily basis and the claim can be easily denied if there has been a mistake in analysis or medical billing and coding errors including many others. Furthermore, there is also a requirement to understand if the claim is of importance because a claim of a very small amount need not be appealed and can be written off but one which is worth a considerable sum needs to be scrutinized. However the physician’s office in this case may need to apply various measures considered the following challenges.

In Denial

The fact that a physician or practice receives the accurate amount of reimbursement even when the claim is not denied is a wrong assumption. Insurance companies may con a physician out of his or her fair share of reimbursements in many ways that are very difficult to detect and need a dedicated and keen professional to find the lacunae in the proper reimbursement of physicians since almost 19% of claims denied are due to errors of the insurance companies. This especially holds true in the case of private insurers due to errors made by the insurance companies in claims and detecting these errors requires skill and sustained effort. As a result some physicians and practices are reluctant to appeal denied or underpaid claims since this may increase the administrative work and expenses. However, nothing can be further from the truth when considering the long term repercussions of the monetary benefits that can be enjoyed even with 5-10% increase in revenue which can be a considerable amount.

The Impact of Reforms

In the face of reforms, revenues are set to increase dramatically along with administrative and billing process as 31 million uninsured Americans receive insurance. Appealing a denied claim is becoming voluminous but the new billing and coding procedures are aimed at making this process of reimbursement or appealing much smoother with the transition from ICD-9 codes to ICD-10 codes and adoption of the 5010 platform and emphasis on quality care and patient privacy through HIPAA compliance. The importance of time and money cannot be overemphasized and denied claims, especially for private insurance companies, have to be appealed within a stipulated period of time after the claim is denied. Therefore preventive steps to save time such as error reduction through analysis and a scientific approach in Revenue Cycle Management (RCM)  is required in order to sustain the low rate of denial over longer periods of time.

Vital Signs

Analyzing the pattern in which claims are denied by an insurance companies and finding out the most common false denials is a crucial part of the process of appealing denied claims. Denied claims can fall in various categories such as:

  • Errors in documentation
  • Services not covered
  • Mistakes in medical billing and coding
  • Technical difficulties involving Electronic Health Records (EHRs)
  • Not considered “medically necessary” by the payer

Arguing your case becomes more difficult due to the huge amount of laws, rules, and regulations that seem to drown the actual cause of the denial. Thus customization of claims becomes much easier when they can be categorized and scientifically solved within a given period of time.

Scientific approach

In this scenario appealing a claim may require more than a standard format and physicians short of time can benefit by acquiring services of a medical billing service. Medical billing and coding experts at Medicalbillersandcoders.com not just perform basic coding and billing functions but are also backed by a team of research professionals who ensure efficient RCM, productive payer interaction, and a scientific approach towards collections with the “bucket” approach in Accounts Receivables (AR) and prompt reimbursements for physicians and practices all over the country with complete HIPAA compliance.


Category : Accounts Receivables / Claims Denials