Sending medical claims to insurance carriers is the simplest aspect of medical billing. The most challenging part of medical billing is dealing with denials.
Here are some tips that I have acquired for dealing with denials.
Thoroughly review the denial This may seem like an obvious step however many medical billers miss the importance of this. It is not enough to simply review a denial from the insurance company, look at an explanation of the denial and accept it as fact. Investigation is a necessary part of medical billing, especially IONM billing. Call the insurance company and ask as many questions about the denial as you need. Don't be afraid to ask and ask again. You'd be surprised to know that most insurance phone representatives don't understand the billing process, coding and your specific denials. If you don't get an understanding about your denial call again, sometimes getting a different representative on the phone can change the entire outcome of the claim.
Research
After you receive a denial that you understand it's time to research. Track other denials you received that are similar. How were they handled before? Was your denial paid before on another claim? If it was paid before, this may be an indicator of an incorrect denial, or a series of errors from the insurance carrier.
Research the coverage determinations for the carrier that denied the claim. Don't forget to reference the Local Coverage Determination from Medicare also.
After you receive a denial that you understand it's time to research. Track other denials you received that are similar. How were they handled before? Was your denial paid before on another claim? If it was paid before, this may be an indicator of an incorrect denial, or a series of errors from the insurance carrier.
Research the coverage determinations for the carrier that denied the claim. Don't forget to reference the Local Coverage Determination from Medicare also.
Most carriers use Medicare's policy to determine coverage of IONM coding.
Appeal
Once you've determined an approach for your appeal. Obtain your intraoperative notes supporting the codes that you billed. Review the records.
Once you've determined an approach for your appeal. Obtain your intraoperative notes supporting the codes that you billed. Review the records.
Don't blindly send an appeal letter with a claim without reviewing the intraoperative notes.
When you create an appeal letter, obtain your supporting documents, past appeals, explanations of benefits, LCD's; have someone else review this. A second glance at your appeal from another set of eyes is always a good idea.
Copy or scan all of your documents and send them to the appeals address. Sending them to the regular claims address may cause the appeal to be rejected. Many insurance companies have a time limit for appeals. This is why it is important to work all your Explanation of Benefits within a week of receiving them. You can avoid issues by getting your appeal out on time.
When you create an appeal letter, obtain your supporting documents, past appeals, explanations of benefits, LCD's; have someone else review this. A second glance at your appeal from another set of eyes is always a good idea.
Copy or scan all of your documents and send them to the appeals address. Sending them to the regular claims address may cause the appeal to be rejected. Many insurance companies have a time limit for appeals. This is why it is important to work all your Explanation of Benefits within a week of receiving them. You can avoid issues by getting your appeal out on time.
Know the rules for the carrier you are appealing. Some insurance companies want appeals in a certain format, others are more lenient. Make sure you know what is expected of your appeal.
Also- remember to keep some form of proof that the appeal was sent. A certified mail receipt is a good form of proof. If for any reason your appeal does not meet it's destination you can use this to prove the submission.
Also- remember to keep some form of proof that the appeal was sent. A certified mail receipt is a good form of proof. If for any reason your appeal does not meet it's destination you can use this to prove the submission.
Follow Up
In order to make sure your appeal is reviewed and your claim is reprocessed you need to have a strategic follow up method. Make sure your appeal was received. Many times after an appeal is sent, billers just wait for a response. Don’t assume you will get one. Call at least 14 days after the appeal is sent. Obtain an appeal document number or claim number. Make sure all your appeal documents were received. Know the number of pages in your appeal packet and make sure the rep can confirm that all pages were reviewed or scanned. Also make sure the document has been forwarded or is being worked on by the correct department.
Once you have all the information needed, set up a reasonable follow up time to call back and see if the appeal has been reviewed.
Lastly, don’t give up. Keep on fighting for payment. If you have followed the rules for appeal and you have all of your supporting documentation don’t take no for an answer. Continue to track your denials and document your entire follow up process. Any claims that you get paid after the appeal can be used as leverage for new denials.
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