It’s very frustrating for healthcare providers not to get reimbursed. The major reason behind delayed/partial payments for the medical services they rendered is the high rate of claim denials. Moreover, physicians’ millions of dollars remain uncollected just because of the inefficient claims denial management.
Claims get denied/rejected when insurance companies refuse to pay for the healthcare services you provided to the patients. Are you struggling with frequent claim rejections/denials? Then don’t worry you have the right to appeal the claims for getting paid.
However, to reclaim your hard-earned revenue, your billing staff must have the in-depth knowledge to handle the denied claims efficiently. Resubmission of medical claims might sound simple.
But in reality, reworking on a rejected claim is more hectic and time-consuming than filing for the first time. It has been estimated that approximately 47% of denied claims remain unattended and don’t ever get resubmitted. That is outrageous. It can impact your entire revenue cycle management drastically.
Are you one of those medical practitioners, who lose a significant amount of revenue due to ineffective denial management? Then relax. You can still recover your lost payments and elevate your profit margins. You just have to ensure an efficient claim denial management system in place.
Make sure that your in-house staff is highly capable and have sufficient time to appeal the rejected claims in a timely manner. However, if it’s not possible for you to deploy an in-house team. Then you must collaborate with the top-rated medical billing companies for better results.
Whether or not you outsource your medical billing services, you must closely monitor the denial management system. And make sure that it’s working according to the following strategies.
1. Identify the Root Causes of Claim Denials
You cannot fix an issue until you get to its root causes. The same is true for claims denial management. Insurance companies send the medical claims back with proper justification and reason of claim denials.
So, in order to identify the areas of improvement and rectifications, the in-depth analysis of rejected medical claims is crucial. This enables you to reach the roots of a particular reason that has resulted in claim denial/rejection. Once you identify the key reasons behind payment denials, you can take further actions to make proper adjustments before resubmission.
It’s pertinent to mention here that the most common reasons that can result in rejected claims are:
- Referral and Pre-authorization Issues.
- Incorrect/missing patients’ information i.e. name, date of birth, gender, age, phone number, address etc.
- Incomplete insurance forms.
- Invalid insurance information or submission of medical claims to wrong payers.
- Duplicate billing.
- Failure to meet medical necessity requirements.
- Medical coding errors such as: unbundling, upcoding, undercoding etc.
- Late submissions of medical claims.
- Failure to Meet Credentialing Requirements.
2. Learn About the Appeal Process
It might be possible that insurance companies have their own and different processes of appealing rejected//denied medical claims. Therefore, check the website of the payors or call customer services to get detailed information on how to file an appeal. Be sure to ask if there is a deadline for filing an appeal.
3. Write an Appeal Letter to payers
A letter to appeal a claim denial can help you to figure out why your claim is being denied or rejected. In this way, you can challenge the decisions of insurance companies for not getting reimbursed. So, it is the first step to claim denials resolutions.
Elements of the letter:
- Patient’s name, insurance policy number, and the name of the policyholder.
- Accurate contact information for both patient and policyholder.
- Date of the denial letter and mention the reason for claim denial.
- Complete and accurate information of the medical provider.
Moreover, the appeal letter should include:
Opening statement:
State the purpose of your writing and reasons for claim denials. Also, enlist which of your medical service or treatment was denied for compensation.
For instance, you can write like this: “I am writing about claim number…… I received a letter denying my claim for XYZ services, for this reason: ______________. I would like to appeal this decision.”
- Explain the history of the medical condition.
- Add authentic Supporting information.
4. Don’t Delay
Timeliness is the most important factor in the entire healthcare revenue cycle management. Therefore, to recover your denied payments quickly. Make sure that claims are being resubmitted in a given time frame specified by the insurance company.
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