Medical Claim Denials

How to Deal With Medical Claim Denials and Rejections

We know you hate medical claim denials and rejections. It can be difficult for practitioners to deal with such denials. The job can be complicated, frustrating, and often very time-consuming.

Knowing how to deal with medical claim denials can save you time and improve your cash flow. Here are some basic pointers to remember:

Review all Information That You Have

Rejections are more common than you’d like to think. About 17 percent of all in-network claims were rejected in 2019 and the number was 14 percent in 2018.

To reduce your risk of medical claim denials, review all the information you have including remittance advice and explanation of benefits.

The notification sent by the insurance provider indicates whether the claim was denied, partially paid, delayed, or paid in full. 

Follow the instructions if the claim stands “contested or unclean”. Correct the issues, if any, and resubmit the claim with any missing information. 

Look for reasons why the payment was declined and make sure to follow the steps provided by the insurance company.

Get in touch with the carrier if the notification isn’t clear. Having a conversation with the carrier can help solve small issues such as an administrative error or poor submission procedures.

Waste No Time

Waste no time and submit and resubmit claims as soon as you can. Most companies and statutes put a limit on when claims can be submitted. Being too late can cause you to lose money. 

Apply Again and Again

If your resubmitted claim gets denied and the denial seems improper to you then go ahead and appeal the decision. Make sure to follow all guidelines and submit the required documents to ensure your appeal gets accepted.

Remember that the process varies from provider to provider, hence check with the carrier. Moreover, state laws also come into play. In most cases, you will have to submit an explanation of why you wish to appeal the decision and provide documents to support your claim. 

You may have to submit documents to demonstrate necessity if your claim got rejected due to a lack of “medical necessity”. Be careful about the information you provide.

All practitioners are required to meet the set obligations under the HIPAA and to only provide what’s ‘necessary’. Working with a HIPAA-compliant company like Medical Healthcare Solutions can help reduce the risk.

Filing another appeal or resubmitting your claim may do the trick. Do not give up just because you are asked to submit the claim again and again. Being persistent shows you’re serious about getting paid.

Understand How to Appeal

Since the appeals process changes from company to company, it is important that you ask questions and ensure you’re fully familiar with it. 

Being aware of the policies will put you in a favorable position to respond to medical claim denials.

Keep a Record

Keep a record of everything related to a claim including the name of the person you’ve been corresponding with. A few more things to take note of include: 

  • Why the company chose to deny, partially pay, or delay the claim
  • How your office followed up
  • The outcome of the follow up

You might need this information in the future when you choose to appeal or file a complaint regarding medical claim denials. Moreover, these records can help face similar situations in the future.