Your Top Denial Management Questions Answered

By Lea Chatham  |  July 25, 2013

In her recent medical billing webinar, Denial Management: Top Techniques that Get Claims Paid, practice management expert Elizabeth Woodcock reviewed her proven four-step strategy for effectively managing denials and getting them paid. She covered a lot of information, and attendees had many good questions. We’ve selected several good questions to share with everyone.

  1. Where can we get the top 10 denials with a reference to the source of this data? Many payers publish the top reasons for their participating providers. The American Medical Association produces an annual report card that includes the top reasons; please see http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/health-insurer-payer-relations/national-health-insurer-report-card/denials.page.
  2. What is the best solution for claims status—calling, online, or written correspondence? To review claims status, the most efficient solution is to make the query online. If there is a problem with the claim, then make contact by telephone. If the issue can’t be resolved with a customer service agent at the payer, then make your case in written correspondence.
  3. Most of our denials are the result of the incorrect information we receive from the payer when we verify benefits. Are there ways to help prevent this? Unfortunately, insurance companies don’t always have the most accurate information when you request benefit information. A patient may have left a job and that cancellation hasn’t shown up in the payer’s system yet. Or there has been some other change that hasn’t been processed. Although there are challenges, it is still always better to check eligibility and verify what you can. I also recommend asking patients when they schedule and when they check in if there have been any changes to their insurance. It never hurts to complain to the payer if you find this to be a problem, and please do have a process to swiftly contact the patient after receiving a denial despite the verification of benefits.
  4. Is it okay to bill a patient if all the research has been made to get a denial paid and you cannot reach the patient by phone? No, unfortunately not. When you receive a denial returned to you, the Claim Adjustment Reason Code will be accompanied by a two digit alpha—CO for “contractual obligation” and PR for “patient responsibility.” If the denial is reported as a “CO,” the payer is indicating that you have a contractual obligation to accept the non-payment. Only if there is a PR can you transfer the balance to the patient. Now, you certainly can communicate with the payer and argue your case, but most denials must be handled directly with the payer.
  5. What are your thoughts on working your A/R based on payer turnaround. For example, Medicare pays in 14 days and Blue Cross pays in 21 days so should we work these within 3 days after the normal clean payment? Following payers’ payment cycles is certainly “best practice”; I think it is reasonable to follow up three to five days after you expect the payment to arrive.
  6. How do I rebill a claim without getting denied for a duplicate claim? I would recommend following the procedure for resubmitting a corrected claim as outlined by the payer; this is often referred to as the “reconsideration” process.
  7. We have many requests for medical records from one insurance company. They request medical records on almost all claims. Is this legal? It seems like a delaying tactic and am considering going to the board of commissioners. I assume that this payer is requesting medical records before payment. (If they are requesting them after payment, that is another issue.) If you feel that this payer is stalling, I would contact your designated provider representative and state your concerns verbally. Then, I would send him/her a letter. I would then ask your physician to contact the payer’s medical director and, again, report it verbally and in writing. Either on this letter to the medical director, or in a separate letter, I would carbon copy the state insurance commissioner.
  8. ur provider sees a lot of out-of-network patients and has had trouble getting the patient payments. What would be your recommendation to collect this money more efficiently?There are many best practices for collecting patient payments. Here are a few suggestions. First, it’s important to have a patient policy in place that states that patients pay co-pays and other patient responsibility at the time of service. It can be at check-in or check-out depending on the situation. It should also lay out self-pay requirements. Preferably all self-pay amounts should be at time of service. Barring that, you might consider offering discounts for self-pay patients who pay within a period of time such as 30 days or charging late fees for those who don’t. You can also let patients know about balances due when they schedule an appointment. While there are other strategies, these are a good starting point.

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