Up your appeals game this year with improved claims denial management to lower your denials and raise your bottom line
Wouldn’t it be miraculous if every bill submitted for reimbursement was paid at the rate expected within 72 hours? Anyone who has worked in a billing department can testify that often this is not the case, but there is always room for improvement with claims denial management.
Denials are a fact of life when dealing with insurance billing. Your appeals game has to be A+ to fight for every dollar your office has earned and deserves. Read on for some tips on how to use your knowledge and savvy to keep your cash flow rolling.
Flex your appeals knowledge to increase your bottom line
Appeals management is an essential skill to prevent your practice from losing monies to erroneous claims submissions, claims denials and even requests for refunds of previously paid funds. Learning all you can about appeals and how to execute them is vital for a successful practice.
Your system of accounts receivable follow-up should include a component that acts on denied claims or recoupment requests. We call this “reactive follow-up,” and it’s part of the day-to-day role of the insurance billing team. Allot time each week to review and investigate erroneous denials to stay on top of this issue. As you investigate, you may come across one of the following issues:
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- Claim denied because service is not included in provider’s scope of practice
- Duplicate co-pay applied on same day of service (one for CMT and one for PT services)
- Specialist co-pay applied to CMT services
- Claim denied because referral required
- Discount plan adjustment applied (silent PPO)
- Request for overpayment (take back)
- Delegated services not allowed
What if the claim is paid 45 days later? Do you know your state statute for prompt payment? What if a silent PPO reduces your claim charges? Does your state have a regulation in place to protect your rights? Do you have a “no referral required” regulation that applies to DCs? What if your claim is denied for “scope of practice”? Do you know how to find the scope of practice for your state? What if the claim denial says, “need a referral”? Do you know if your state has a direct access law in place for DCs?
The ability to locate this information online allows you to include it as supporting evidence with claims denial management and can impact the outcome of your appeal. Be sure you have a robust system for dealing with each of these. It always starts with initiating an appeal or a reprocessing request. Do you know the difference?
Appeal or reprocess?
Whether you file a formal appeal or a quick and easy reprocessed (resubmitted) claim, there is a difference between the two:
An appeal is a formal action taken when a claim is not paid for clinical reasons (e.g., there was a question about the medical necessity of a procedure or treatment).
Reprocessing is an informal action and is necessary when a denial is for a technical reason (e.g., missing information, an incorrect ID number, wrong birthdate for primary insured or a missing diagnosis code). Electronic and/or paper billing edits may help avoid these types of denials.
If the denial qualifies for an informal appeal (e.g., reprocessing a corrected claim), a phone call may be all that’s needed to resolve the issue. If the denial was based on a verified benefit, call the insurance provider’s customer relations department, provide the verification information and the reference number, and ask the representative to reprocess the claim accordingly. Whenever possible, handle your claims denial management over the phone or through online portals. If the issue is clinical in nature or the content is complex, a formal or written appeal may be necessary.
Evidence to support your appeal: appeal letters and forms
If you receive a denial from an insurance carrier other than Medicare, you may request a provider inquiry, which is the first level of appeal and must generally be submitted within 18 months of the date of the provider’s remittance of the original claim. The statutes may vary; follow the instructions carefully on the denied EOB and/or the payer’s policy.
Depending on the carrier, claims denial management may involve filling out forms supplied by the carrier and/or drafting an appeal letter — either way, the payer always asks for supporting documentation. If your claim is denied for medical necessity, attach the exam findings, outcome assessments and documentation notes with your appeal letter.
Some carriers will require a specific form (e.g., Request for Claim Review, Managed Care Program Provider Appeal, Request for Appeal or Reconsideration). These can be found on the carrier’s website along with instructions for submittal. Complete the form with patient-identifying information, service-specific information, reason for the request, details of the request and any supporting documentation.
If a form is not available, submit an appeal letter. Include all supporting documentation that substantiates your position in the request for a claim review. The following specific information must be included in your letter: Beneficiary name, membership number, date of birth, claim/reference number of the denied service, the amount billed, their reason for the denial (i.e., their denial code), the reason you are appealing and the signature of the appointed representative.
The appeal letter should include the nature of your appeal based on the patient, the specific elements of the condition, and the supporting documentation contained in the patient’s record.
Keep the letter brief. Avoid emotional statements or unnecessary information. If you’re unsure what to say in these appeal letters, reach out to a professional for assistance to create a template you can customize to use. Keep a dated copy of what was sent to the carrier. Place a reminder in your tickler system to follow up by an appropriate date. If you do not receive a response to your appeal or the denial was upheld, follow the insurer’s instructions for a second-level appeal.
Claims denial management: get the department of insurance involved
After completing all levels of appeal with the insurer and if the original denial is upheld, you may need to notify your state department of insurance (DOI) of the problem. Getting the department of insurance involved may prove helpful, as they have additional support to further the case.
It is their goal to track any fraudulent insurance dealings. Provide the DOI with all correspondence and responses sent to and received from the insurer. Be aware of all your state statutes and confirm your complaint is valid. The mission of the department is “to protect the public and make insurance available and affordable by efficiently providing quality assistance, providing fair regulation for industry, and promoting a healthy, competitive insurance market.”
To notify the DOI, verify your DOI’s address and determine whether any additional documentation or forms need to be submitted with the complaint.
Note: Even if a third-party administrator (TPA) is involved, you must report the insurer to the DOI. DOIs usually do not have regulatory authority over TPAs, but they need to be aware of the claims that are being rejected or reduced. The DOI can hold the insurer responsible, and since the TPA is answerable to the insurer, the insurer can manage the TPA. There are also exceptions regarding ERISA plans (which the DOI does not regulate).
Need help finding your state department of insurance? Here are some steps to follow:
1. Locate the National Association of Insurance Commissioners at: naic.org/state_web_map.htm
- Locate your state. Click on the embedded link. It will take you to the state department of insurance.
- Look for a link to the statutes and regulations. Click on that link to reach the state regulations site.
- On the search bar enter chiropractic. Result: a list of all regulations that reference that subject or content.
Note: You may want to write down the regulation numbers on that page so you can search appropriately. If you click on the link provided, you are often taken to the full page of regulations. Use the numbers to refine your search further.
Once you obtain the information you need, print a copy for your records. It can help to keep a binder for all state regulations that pertain to chiropractic and bookmark the government site that provides this information.
Move it up the chain
Sometimes, the issue needs to be managed at a higher level. Your national and state associations may need to know about an unfair policy used for denial. Often, these can be addressed at the higher level and solved for all.
As a member of your association, they want to hear from you. And, armed with the knowledge you need, don’t hesitate to appeal claims that are not paid. Sometimes, it’s just a learning experience, and sometimes, you may just get a check in the mail because of your great effort.
KATHY WEIDNER, MCS-P, CPCP, CCPC, CCCA, better known professionally as Kathy Mills Chang, is a Certified Medical Compliance Specialist (MCS-P), a Certified Professional Compliance Officer (CPCO), and a Certified Chiropractic Professional Coder. Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Nearing her benchmark of serving this profession for 40 years, Kathy leads the largest team of certified specialists under one roof in the profession at KMC University, and is known as one of our profession’s foremost experts on Medicare and documentation. She or any of her team members can be reached at 855-TEAM-KMC or info@KMCUniversity.com.