Handling Your Claims Denials
Handling Your Claims Denials
Most denials from insurance companies are not related to coding but are related to demographics, enrollment, eligibility, and preauthorization. A practice will receive one of three responses after submitting a claim.
- All line items on the claim are paid, and paid amounts are correct
- The claim is denied outright (more likely to be related to patient eligibility, provider enrollment, or preauthorization)
- The claim is partially paid (one or more line items on the claim were denied/ allowed amount was inaccurate)
A claim that is denied without any payment is routed to the appropriate staff member on the basis of the reason for the denial. Payers use standard reasons for claim denials, which allow a practice to sort the denials into work queues. Coding-related denials are sent to experienced coders for further investigation. Eligibility and preauthorization denials can often be sent to staff members other than coders—for example, a biller or front desk manager. Provider enrollment denials are sent to management. Even with these reason codes, some practices find that they need to call the payer to understand the reason for the denial.
To know whether the payment allowance is the right amount, a practice must load each payer’s fee schedule into their software and monitor variances in the allowance. The fee schedule amount and the paid amount may not be the same if there is a deductible amount due from the patient. But the allowance should be correct.
A fourth possible scenario is no response: The payer neither pays nor denies the claim. Payer contracts have short filing limits, and medical practices need to monitor their insurance due to receivables closely.
Many practices track the number, dollar value, and reason for all denials, by the payer and by type of service. This allows the practice to improve internal processes to prevent future denials that could have been stopped before submission. It also gives the group important information about payers that process claims incorrectly, and a chance to discuss that problem with their provider representative or medical director. Payers limit the length of time in which a claim can be resubmitted or appealed. A practice must assign a staff member to actively monitor claims status and make sure that denied claims are researched, corrected if needed, and resubmitted or appealed.
It’s been estimated that some practices can lose thousands of dollars if a physician doesn’t stay on top of collecting outstanding balances and resubmitting denied claims within the time allowed. The importance of tracking claims denials and staying on top of resubmitting them cannot be overestimated. E2E Medical Billing Services can assist you in handling your denials. To know more about how we can increase your revenue by eliminating denials you can call us at 888-552-1290 or write to us at info@e2eMedicalBililng.com