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Appealing Denied Medical Claims

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When done correctly, appealing medical claims can be an effective way to resolve and receive payment for those claims that are denied due to reasons other than for simple registration errors. Some claims are easier to resolve than others due to a coding or billing error. Others may be more complicated. Before filing an appeal, it is important to evaluate the claim to determine whether it is worth spending the time and money.

Set a Dollar Amount. Depending on the average dollar amount of your medical claims, it is important to set a dollar amount for claims that have been denied to be appealed. Some facilities choose to only appeal claims higher than $9.99. If your medical office has claims that have a high value or have a lot of outstanding accounts, it may be in your best interest to set your appeal amount higher to make sure that valuable time is not spent on chasing low dollar accounts. This also includes line charges that are denied for no medical necessity or other reasons by the insurance company.

Review the Denial Reason. The reason a claim has denied is important when deciding to file an appeal. If you believe the insurance company wrongfully denied your claim then you should definitely make an attempt to appeal their decision. One popular denial that can be easily appealed is for no prior authorization. Many times authorization has been received for the patient's treatment but many times is left off of the claim form. This should be an easy fix especially since the insurance company provided the authorization in the first place. You may be able to correct this denial with a simple phone call, refile the insurance claim or submit an appeal letter.

Don't Delay. Try to submit your appeal within 7 days from receiving a denial notice. The longer you take to resolve a denial, the lower the chance you have of getting your appeal approved. Each insurance company has a timely filing deadline and sometimes when claims are not resolved right away, they can be left in accounts receivable for too long failing to make the filing deadline.

Get the Patient's Help. Patient's can be your best resource when having trouble getting insurance companies to pay claims. The patient may not think they can be of an benefit but there are two great motivators to get them on your side. One - patient's pay a lot of money in insurance premiums for their insurance and if the insurance company is not paying their part, patients may see them in a negative way. Remind patients that the purpose of the insurance company is to help pay their medical bills. It would be helpful if they called the insurance company on your behalf. Two - many times if the insurance company does not pay, the patient is ultimately responsible for paying the bill depending on the denial reason. Again, remind patients that they are responsible for the bill and if the insurance company doesn't pay, they will have to. Many patients are willing to contact the insurance company rather than pay the claim themselves.

Know the Your Contract. Some denials your medical office receives may be against the conditions of your contract. Specifically, it is important to know and understand "Covered Services" and "Compensation". This information can be useful in appealing claims that should never have been denied in the first place.

Use Outside Resources. If necessary, take advantage of outside resources to help get your outstanding denied claims paid. Use the services of an outsourcing agency or provide your staff with job aids to get the job done.

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