Secret of Reversing a Denied Insurance Claim

Medical insurance claim denials can be very costly to the medical office and to a billing service. Denied claims must be investigated to see why they were denied and what must be done for the provider to be reimbursed for the service. Some denials are legitimate. The services may simply not be covered under the patient’s insurance plan. Many are in error or may be due to an issue that can be corrected and then reprocessed by the insurance carrier. If an insurance claim is denied but you believe it should have been paid there is one secret to the successful resolution of that claim. That secret is…

Persistence

It may take as many as six resubmissions and/or up to eight phone calls as we recently experienced but you must stay on top of it to get final resolution. One of our favorite providers saw a patient for several counseling sessions and the claims came back denied stating the patient had no coverage with that plan. We reported this information to our provider who then checked with the patient. The patient called United Healthcare and straightened out the coverage issue. The provider called us back and advised us that the issue was resolved and asked us to resubmit all of the visits. All claims were resubmitted but three weeks later another denial arrived still stating the patient had no coverage.  After speaking to a customer service representative we were told that the patient is still not a member of that plan. We explained that the patient had called and straightened out this issue.   After a lengthy hold, the customer service representative returned and advised us that the patient did indeed have coverage. We were told to resubmit the claims again.

After not hearing on these claims for another month we called back and were told the claims were now denied due to the CPT code. They stated that the provider was not authorized to bill for the extended visits. However the provider did have the appropriate authorization. The customer service representative advised us that the claims would be sent back for reprocessing. We heard nothing for another month and called back to find that the claims were not put back through for reprocessing. Three weeks later we called back and were told that they were still being reprocessed. A month later we received a denial stating the claims were denied by the Medicare system.

We called back and explained that these were not Medicare claims and should not have gone through the Medicare system. The representative offered to send them back for review. A month later we called back to find that they no longer have a record of the claims with the appropriate id number. They asked us to fax them in. Faxed, called, verified receipt! A month later we got paid for 2 of the six claims. I would like to say that it was finally resolved, but we are still waiting for payment on the final four claims which of course we called back on once more.

Obviously we will not recoup all the expense of this lost time in tracking these claims. But this is work that must be done. It all averages out in the end. The bottom line is that it may be necessary to follow up multiple times on problem claims. If this is not done much money can be lost. Hopefully you never run into one this involved.

If you are having issues with denied claims and do not know how to get the best results, check out our ebook “Denials, Adjustments and Appeals”

 

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9 Responses to “Secret of Reversing a Denied Insurance Claim”

  1. Tawny Dietrick Says:

    Good article! This is typical for that insurance company though. Hate it when I have to get an issue resolved!

  2. Cheryl Schmidt Says:

    It took me 2 years and multiple billings but I finally got the claim paid for on entire month & half’s worth of visits. Over 12 hundred dollars! When I win its all worth it.

  3. Stephanie (Denison) Koiner Says:

    So, were you talking to CSR’s in India or were they in the states? Just curious. I used to request to speak to an onshore rep when I had to deal with denials or anything beyond some basic issue.

    • solutionsmedicalbilling Says:

      Hi Stephanie!
      Unfortunately we were dealing with reps in the states.

      • Stephanie (Denison) Koiner Says:

        Ugh! I remember one claim that was such a jacked up mess on their end, that I asked the rep if monkeys on crack had processed the claim! She did admit the claims were being processed overseas, so that that is why I asked. It was so messed up that she couldn’t even figure out what happened. The EOB breakdown didn’t even total up to the check total.
        Persistence will usually pay off and sometimes getting provider relations can help. Just think how much money the insurance carrier saves when an office doesn’t have the time, manpower or knowledge to keep appealing and arguing for that money!

      • Stephanie (Denison) Koiner Says:

        I have also gone so far as to file a complaint with the state board of insurance on a claim for hearing aids that Humana kept denying. Shortly after I filed my complaint, the claim was processed and paid correctly.

  4. Susan Swenson Says:

    I have found that utilizing insurance website portals has been advantageous to our company to avoid a lot of eligibility claims processing concerns and long phone calls and hold times. That is, if the company has a website and if that website is working.

    • solutionsmedicalbilling Says:

      Good point Susan! Yes we to use the websites whenever we can. They can save a lot of phone time. I wish all the insurance carriers had good websites.

  5. Preethy Says:

    You are correct susan. I had faced the insurance fake denials like you stated. Even I had appealed more than 7 times and finally received payment for year 2011 DOS in the Year 2014. Good Article!!


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