Don’t Take Rejections Lying Down

Posted on 25 Jun, 2018 |comments_icon 0|By Elizabeth

Recoup lost revenue by following up on denials.  

After a claim has been properly documented, coded, and submitted for payment, a few things could happen. Hopefully, the insurer pays the claim and the office receives the appropriate reimbursement. But there are other scenarios that could also happen that require follow-up. Let’s review some of them next:

Pick low hanging fruit first.  The insurer may reject the claim because of an error on the claim itself. This could be a simple mistake like a required field being left blank, a code being truncated, or the claim not having the appropriate designation of who provided the service. A rejected claim doesn’t even make it in the door at the insurance company. The good thing about these types of claims, though, is that after the correction is made, the claim can be resubmitted.

Know the rules.  The insurer may deny a claim for a multitude of reasons. Perhaps the service was not medically relevant for the patient, too many services were provided in a given period of time, or no authorization had been made prior to the service being rendered. These are just a few of the many reasons an insurer may deny a claim.

It’s up to the coder to know what codes can be submitted with what diagnoses and what additional documentation might be necessary for the service to be appropriately submitted and paid. Different insurances reimburse differently. Not all insurances, or payers, cover the same services and procedures. Coders need to be familiar with payers’ coding, billing, and reimbursement rules to ensure they code correctly. This is why it cannot be stressed enough that all reference material should always be current and all bookmarked website sources should be updated regularly to make certain the most current information is being used.

Take a team approach.  Even when all the requirements are met and the claim is completed appropriately, there still may be a reason it is denied. Your follow-up team could include insurance specialists, clinicians, customer service representatives, and coders.

Creating a full-service follow-up team affords the practice or group the ability to follow through on all claims to the various paying entities as well as answer patient questions about their bills and claims. The follow-up team should have the knowledge to know what to do for each claim that is not reimbursed in a timely fashion.

The following examples outline reasons why payers may deny bills, or claims, that the providers send:

  • Conflicting dates. This could be that the service was denied because the patient didn’t have coverage at the time or service or that the physician wasn’t yet a participating provider for the insurance. Certainly there are many reasons and the follow-up team would be the ones to handle these, correct them, and resubmit the claim or submit an appeal for the service.
  • Wrong payee. The claim may have been paid by the insurance company, but the payment was sent to the patient. Phone calls might be warranted to the patient to get the money routed to the practice. The follow-up up team could be responsible for these calls as well.
  • Additional information needed. The claim could be held in a pending status at the insurance company because they need additional information. Usually, this is in the form of documentation by the physician. However, it could also be information from the patient about other insurance or updated information. For example, a medical insurance plans usually want to know if an injury would be covered by auto insurance or worker’s comp insurance before paying. Usually, the insurance will alert the office when such a circumstance occurs. However, with the number of claims that could be flowing through this cycle, the follow-up team could be deployed to find out the status of claims that have not yet paid.
  • Involvement of other payers. Once the insurance company pays a claim, there still may be a portion owed by another insurer or the patient. Collectors, customer service representatives, client service specialists, (or any number of titles for these people) could be the ones to prepare the claim for the next insurance, if the billing system doesn’t do it automatically. Or perhaps, they would be the ones to call the patients to set up payment arrangements.

This follow-up team, made up of billing and/or collections specialists, is only as good as the information they receive. That is why the entire revenue cycle must be thorough and timely. If the scheduler doesn’t gather the most current insurance information, no matter how detailed the documentation and skilled the coder, the claim may be denied. If the physician doesn’t document a service fully or at all, the revenue cycle stumbles. All of the gears of the revenue cycle should be well-oiled and comprehensively maintained, meaning that the entire team working for a provider must perform their duties correctly and on time.

Get to know Coding Principles

Medical Coding Demystified: Coding 101 for Non-coders 2018 is an indispensable resource to learn medical coding.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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