Obamacare is putting a lot of pressure on the profit margins of medical insurance companies. Due to this pressure insurers are denying more claims and increasing their interference between the patients and physicians as far as the medically necessary care is concerned. Claims denials have also increased due to the complexities in coding and billing.

Physicians have to follow a time consuming procedure of dealing with an insurer in case of claims denials; however, they can resolve and receive payments by appealing those denied claims. The success of appeals procedure can help physicians maximize their revenue.

Most Common Reasons for Payment Denials

Mentioned below are some of the common cases of insurance claims denials that need to be avoided:

  • Claim submitted for a service that isn’t covered under the insurance plan
  • Lack of required information for insurance company
  • Claim submitted for a procedure that is cosmetic, investigative / experimental or medically not necessary
  • Claim submission deadline not met

These are some of the reasons due to which medical insurance companies deny claims. However, an error-free appeal procedure can ensure payment for the denied claims due to reasons other than simple errors during registration.

Evaluate Authenticity of Reasons for Denial

The evaluation of a denied claim is the most important part of filing an appeal. This helps in determining whether following up on the claim is worth spending the time and money. If the billing team feels that the claim was wrongfully denied by the insurance company, an attempt should be made to contest the insurer’s decision.

Avoid Delays in Appealing Denied Insurance Claims

There should be no delay in submitting the appeal. It should be done within seven days from receiving the denial notice. If the appeal submission is delayed, the chances of getting it approved will reduce. The failure to resolve denied claims right away results in the claims being left in AR for too long, affecting the cash flow for physicians.

Ask for the Patients’ Assistance

Practices shouldn’t refrain from taking the patient’s help when it comes to appealing a denied claim. Since the patient would want the insurance company to pay for the rendered services, it would be great if they too call the company on behalf of the practice. Many patients don’t mind calling up the insurance company in case of a denied claim as long as they don’t have to pay the claim on their own.

At times, medical offices receive denials that are against the conditions of the contract set between the insurance company and the practice. Therefore, it is important to understand all the details related to “Covered Services” and “Compensation” before appealing the claims that shouldn’t have been denied by the insurer.

Other Solutions to Consider

If your practice can’t pursue appeals due to lack of time, money and skilled staff, outsourcing can be an effective solution. Many practices have outsourced their billing requirements to companies like MedicalBillersandCoders.com that have a team of skilled billers and coders. MBC has been helping practices all over the US for over 40 specialties to sail through claims denials issues. Their team handles all aspects of successful claims filing to ensure maximum revenue for practices.

Published By - Medical Billers and Coders
Published Date - Nov-10-2014 Back

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