You can defeat these common claim denials
You can defeat these common claim denials
Acquaint yourself with state regulations
Tammy Tipton has seen it all. Her Lewisville, TX, health care consulting firm Appeal Solutions specializes in helping medical practices appeal denied claims. Here is Tipton’s list of the four most common reasons for claims denials and what you can do about it:
• Timely filing. Commercial carriers have routinely allowed claims to be submitted a year or more after treatment. But managed care companies require that claims be filed within 60 to 90 days, and failure to do so can result in outright denial, Tipton says.
But it never hurts to appeal, she adds. If there is a mitigating factor that makes your claim late, such as your office converting to new software, definitely point that out in the letter.
Any time you can present regulatory information in your appeal letter, do so. For instance, in an appeal letter on a timely filing denial, you can point out a case where the court has ruled against the insurance company. There is software on the market that gives physicians access to regulatory information, Tipton says.
• Lack of precertification. Review the claim to determine if there are any arguments that the treatment was on an emergency basis. Some emergencies are a gray area. If the doctor calls it an emergency and the insurance company denies it, send a letter from the physician saying why the treatment was an emergency, Tipton says.
Most states have specific regulations that deal with denials because of lack of precertification, Tipton says. Check out your state insurance code and your contract with the MCO to see if you have grounds for appeal.
• Downcoding. When the insurance company routinely "downcodes" or changes the treatment code to a less intensive category, this can significantly affect your bottom line, Tipton says. In the case of downcoding, you seldom get satisfaction from just one appeal letter. But on the second or third time, you may get through to a higher level of medical staff who can see that the downcoding was incorrect, she says.
• Medical necessity. This is a gray area that results in a lot of claims denials, Tipton says. Have the attending physician write a letter of medical necessity to accompany your appeal letter. If the first appeal doesn’t work, go on up the ladder at the company until you find someone who can understand the situation, she says.
For instance, if a claim for a neurosurgical procedure is denied because it is deemed not to be medically necessary, Tipton seeks someone at the insurance firm who is knowledgeable about neurosurgery.
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