The procedure of appealing an
insurance claim is intricate, although it can be successful if completed
properly because there are many grounds for claims to be denied by an
insurance company or a payer. The payer collects a lot of claims on a
daily basis and the claim can be easily denied if there has been a
mistake in analysis or medical billing and coding
errors including many others. Furthermore, there is also a requirement
to understand if the claim is of importance because a claim of a very
small amount need not be appealed and can be written off but one which
is worth a considerable sum needs to be scrutinized. However the
physician’s office in this case may need to apply various measures
considered the following challenges.
In Denial
The fact that a physician or practice
receives the accurate amount of reimbursement even when the claim is not
denied is a wrong assumption. Insurance companies may con a physician
out of his or her fair share of reimbursements in many ways that are
very difficult to detect and need a dedicated and keen professional to
find the lacunae in the proper reimbursement of physicians since almost
19% of claims denied are due to errors of the insurance companies. This
especially holds true in the case of private insurers due to errors made
by the insurance companies in claims and detecting these errors
requires skill and sustained effort. As a result some physicians and
practices are reluctant to appeal denied or underpaid claims since this
may increase the administrative work and expenses. However, nothing can
be further from the truth when considering the long term repercussions
of the monetary benefits that can be enjoyed even with 5-10% increase in
revenue which can be a considerable amount.
The Impact of Reforms
In the face of reforms, revenues are set
to increase dramatically along with administrative and billing process
as 31 million uninsured Americans receive insurance. Appealing a denied
claim is becoming voluminous but the new billing and coding procedures
are aimed at making this process of reimbursement or appealing much
smoother with the transition from ICD-9 codes to ICD-10 codes and
adoption of the 5010 platform and emphasis on quality care and patient
privacy through HIPAA compliance.
The importance of time and money cannot be overemphasized and denied
claims, especially for private insurance companies, have to be appealed
within a stipulated period of time after the claim is denied. Therefore
preventive steps to save time such as error reduction through analysis
and a scientific approach in Revenue Cycle Management (RCM) is required
in order to sustain the low rate of denial over longer periods of time.
Vital Signs
Analyzing the pattern in which claims
are denied by an insurance companies and finding out the most common
false denials is a crucial part of the process of appealing denied
claims. Denied claims can fall in various categories such as:
- Errors in documentation
- Services not covered
- Mistakes in medical billing and coding
- Technical difficulties involving Electronic Health Records (EHRs)
- Not considered “medically necessary” by the payer
Arguing your case becomes more difficult
due to the huge amount of laws, rules, and regulations that seem to
drown the actual cause of the denial. Thus customization of claims
becomes much easier when they can be categorized and scientifically
solved within a given period of time.
Scientific approach
In this scenario appealing a claim may
require more than a standard format and physicians short of time can
benefit by acquiring services of a medical billing service. Medical billing
and coding experts at Medicalbillersandcoders.com not just perform
basic coding and billing functions but are also backed by a team of
research professionals who ensure efficient RCM, productive payer
interaction, and a scientific approach towards collections with the
“bucket” approach in Accounts Receivables (AR) and prompt reimbursements
for physicians and practices all over the country with complete HIPAA
compliance.
