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…
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”