Health insurance claim denials can be a major headache. They can lead to financial losses, increased administrative burden, and frustration for you and your staff. Even worse, they can delay or prevent patients from receiving the care they need and impact the patient experience.
Here are a few tips to reduce your risk for claim denials:
- Hire knowledgeable revenue cycle associates and provide continuing education and training.
- Leverage technology and optimize your claims management software — automating simple, repetitive tasks can allow more time for human review of more difficult claims.
- Understand payer policies and procedures for submitting and processing claims — these are usually found on a payer’s website, or you can contact their customer service department.
- Verify updated information and insurance coverage with patients prior to each visit.
- Submit complete and accurate claims with all required information and documentation.
- Use data analytics to evaluate and classify denials; consider creating a task force on your team or utilizing an external partner who specializes in analyzing denial trends.
- Administer corrective action plans to help manage backlogs and denial queues.
How To Get Insurance Claims Approved
Dealing with health insurance claims can be a maze, but with the right knowledge and strategies, you can increase your chances of approval. Whether it’s a routine checkup or a more complex procedure, understanding the underlying processes can make all the difference. Here are some practical tips and strategies to help you navigate the world of health insurance claims, ensuring you get more claims approved without unnecessary delays or complications.
Before the patient is seen, ensure any procedures or treatments requiring prior authorization are obtained before providing the service, and be aware of the payer’s timely filing limits.
To make sure your associates are well-versed on each insurance company’s requirements for claims submissions, or at least how to quickly find that information.
Such as diagnoses, treatments, procedures, and any supporting evidence, before submitting the claim.
To ensure that you’re using the most accurate and current codes for procedures and diagnoses.
Discussing treatment plans, potential costs, and any services that may not be covered by their insurance.
To reduce errors and speed up the processing time.
To ensure that they are being processed in a timely manner.
Keep records of your attempts to obtain prior authorization and any contact or attempts to contact the payer, including dates and times and the responses you received.
Once you’ve submitted a claim, you can increase the chances of it being approved when you:
- Follow up with the payer if you haven’t received a response within a reasonable amount of time to make sure they received the claim and it’s being processed.
- Provide additional information, such as medical records or prior authorization, if the payer requests it.
- Appeal denials promptly by proving validity, making corrections, or submitting any additional documentation or information requested by the insurance company.
Take Control of Lost Revenue With a Partner Who Knows How to Find It.
Schedule a ConsultationHow To Fight Claim Denials
To fight claim denials and possibly get claims reprocessed and paid:
- Review the denial reason carefully to understand why the claim was denied and what you need to do to appeal the decision.
- Appeal the denial promptly, as most payers have a deadline for appeals.
- Gather supporting documentation, like medical records, prescriptions, referral forms, and prior authorization, to support your claim.
- Supply a “Letter of Medical Necessity” from the physician if the claim was denied for lack of medical necessity; this letter should explain why the service or treatment was medically necessary for the patient.
- Contact the payer’s customer service department for assistance if you’re having trouble with, or have questions about, an appeal.
Here are some additional tips for fighting claim denials:
- Be persistent and don’t give up if your appeal is denied the first time.
- Be organized by keeping track of all your documentation and correspondence with the payer.
- Be professional and courteous when you’re communicating with the payer.
By following these tips, you can reduce your risk of claim denials, be more prepared to fight denials when they occur, and get your claims paid more quickly and easily.
Fighting claim denials can be time-consuming and frustrating, but it’s important to remember that you’re not alone. Resources are available to help you, including payer websites and policy documentation, as well as several revenue cycle management associations that offer education and certifications. To help you code your claims correctly, utilize the American Medical Association’s Current Procedural Terminology (CPT) codebook and the Healthcare Common Procedure Coding System (HCPCS).
Or you can streamline your team’s workload by collaborating with an experienced partner. With EnableComp as a partner, you can greatly reduce your risk of claim denials with our proven expertise and proprietary technology that allows our team to submit most of our claims electronically — the rest of the industry submits only 5% that way! EnableComp’s system utilizes data analytics to identify discrepancies and ensure compliance with payer policies and CMS requirements. Our team of experts ensures accurate billing and coding, while our data modeling system continuously learns payer behavior and provides real-time analytics. We also provide detailed root-cause analysis reports to help you reduce and prevent denials.
