Medical billing is a complex process involving many parties and set stages that must be followed to make sure that payments are made on time and accurately. Good medical billing can make or shatter a hospital, lab, or practice. In this blog, we will explore the appeals process and how to set up a reliable medical billing system to ensure your appeals are handled quickly and accurately to create a solid revenue system.
Medical billing denials are not only a problem for the company’s emergency medicine group but also a major drain on ED efficiency and operations, causing significant revenue loss. Despite extensive denial management efforts, medical billing denials are a widespread nuisance that plagues various companies and organizations, so this article focuses on common reasons for medical claim denials as a means to overcome them.
What is an Appeal?
- An appeal is a written request by a doctor/organizational provider to change:
- Adverse decision on reconsideration
- Adverse initial claim decision based on medical necessity or experimental/investigative coverage criteria
- Adverse Initial Use Review Decision
- Denial of non-inpatient hospital services that have been denied due to failure to obtain prior consent
Claims decisions are decisions made during the claims umpiring process. For example, a decision linked to the provider agreement, our claims payment policy, or a processing error.
Utilization review decisions are decisions made during the precertification, concurrent, or retrospective review process for services that require precertification. For these types of issues, the master and provider organization appeals process only applies to appeals received after services have been rendered. The projection appeals process applies to appeals of pre-service or concurrent medical necessity determinations.
Learn About Appeal the Process:
If your insurance company refuses to pay the insurance benefit, you have the right to file an appeal. The law allows you to file an appeal with your insurer as well as an external review by an independent third party. You must follow the process for canceling your plan.
Check your plan’s website or call customer service. You will need detailed instructions on how to file an appeal and how to complete specific forms. Be sure to ask if there is a time limit for filing an appeal.
If you are appealing, tell your doctor or hospital. Ask them to hold off on sending you bills until you hear from your insurance company. Also, make sure they don’t turn your account over to a collection agency.
File an Internal Appeal:
Complete all forms required by your health insurance company. You can often find these forms on their website or they will mail them to you. Do not forget to include the claim number and your health insurance company identification number. You can also include any documentation you want the insurance company to consider, such as a letter from your doctor.
Submit a formal appeal letter. Be sure to include all relevant details, including your name and contact details, claim number, and health insurance identification number.
Remember to always keep copies of all forms and letters you send and remember to send them by registered post.
Overlapping claims occur when the service period of one claim overlaps with the service period of another. This is quite different from duplicate billing and often occurs when a patient seeks health care from more than one provider. If the rejection offers adequate information about the overlap, it is possible to fight it.
Now that you are aware of the most common medical bill rejections, you can come up with a sophisticated plan to avoid them.
Review Your Policy:
See the performance overview in your insurance documents. The paperwork must state what it covers. It must also list limitations or barring, which are things your insurance won’t cover.
Then read the letter or form your insurance idea sent you when it denied your claim. The letter should tell you how to attract your health plan’s decision and where you can get help starting the process.
Inadequate documentation rejections are usually mild rejections and you will most likely be able to correct any errors and resubmit the claim. These denials of health care are due to a lack of documentation; either the required documentation cannot be provided at all, or it can be provided but not received. Documentation does not always appear within the time frame explicitly stated by the payer. In other cases, inconsistent or insufficient information cannot be received and claims are not denied. However, these claims can be appealed by completing and submitting additional details as requested by the payer.
Strategies of Medical Billing Denial
Although most medical bill denials are preventable, the problem continues unabated. Implementing a denial prevention strategy that includes the following can help reduce the risk of a claim being denied:
- Know the types of rejections your practice is receiving.
- Track rejections – identify the source and root cause of rejections.
- Monitor the net claims ratio.
- Prioritize medical billing and coding oversight.
- Determine what corrective actions to take and where they will have the greatest impact.
- Choose comprehensive revenue cycle management software.
- Take benefits of advanced analytics and artificial intelligence.
Good communication is the way to any successful billing process and especially the appeal process in medical billing. Good medical billing can make or shatter a hospital, lab, or practice. It starts with understanding your payment systems and requirements, through working with your patients to understand their financial responsibilities and coverage details, and ends with your team working hard to ensure your appeals don’t end up in the forgotten (or ignored ) piles of paperwork… In between, there are many layers and details that all play an important role in the appeals process: tracking details, filing requirements, payment statuses, and tracking, tracking, tracking. If you don’t have the time or resources to make sure your appeals process is in good working order, you may want to consider working with a revenue cycle management (RCM) resource provider to consolidate this important part of the RCM lifecycle.