5 Things Provider Offices Need To Know When Resolving Health Insurance Claim Denials

Whenever I meet or speak to healthcare administrators the #1 concern is how to get XYZ health insurer to pay for denied services. I then ask, what’s your process to have the payer review the denials??

Most use 1 of 2 methods. (1) Hire billers to call the insurance company and ask what code or documentation is needed for the claim to pay or (2) Outsource the denial management process altogether.?

One would think that if you have a company that specializes in payer relations or an in-house team working your claim denials, over time you’d automatically see less. But that’s typically not the case. Here’s why. Both of these processes tend to focus on managing volume, rather than decreasing the volume.?Adding more bodies to any process, without first determining where the breakdowns are, only complicates it. Health insurance and healthcare are intensive and confusing enough, without adding administrative layers to it.

1. Not every denial will get paid - Don’t spend a lot of time going back and forth with payers over denials that are not likely to be overturned. Many soft denials for front-end claim edits like timely filing, authorization or referral not obtained, non-covered services are not payable unless you can demonstrate that the error was on the payer’s end.?
2. Service denials in batches, rather than individually - Denials do not happen in silos. Look for the patterns. Are there specific codes or code combinations that deny frequently?
3. Identify root cause - If you want to start seeing a decrease in service denials, you need to understand how & why the denial was created.
4. Develop consistency in addressing like denials - One person shouldn’t be calling the customer service team, while another goes straight to the appeal process for the same denial reason. Every team member should be servicing denials the same way.
5. Take the time to read provider communications - Yes, there’s a lot of mail coming into our inboxes but there’s also a lot of relevant and pertinent information in the provider communications. Don’t overlook them as they will have reminders, policy updates & process changes.

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