You’ve just opened the mail to discover several more denials by insurance payors. With reasons ranging from non-covered services to lack of proper documentation, battling back the seemingly never-ending tide of denials can feel like a full-time job. No-win appeals.
Not only do stacks of denials seriously eat into the time you could be spending on other tasks, but they also cost your practice revenue and slow down collections.
While some appeals are a simple matter of amending codes used or sending more documentation, not all appeals are winnable. And with insurance companies sending out more and more denials each year, stemming the tide of permanent denials can seem impossible.
Rather than spending your time trying to appeal every single claim denial that crosses your desk, focusing on the appeals you can win is a better use of your time. If you quickly weed out those no-win appeals, you’ll be better equipped to fully pursue the ones that will matter.
To help you determine what to tackle first, here are the top 3 no-win appeals situations:
No Prior Authorization No-win appeals
Prior authorization is a cumbersome process, especially when your team is already strapped for extra time. And because insurance companies change the rules each year, keeping up with what does and doesn’t need prior authorization can be frustrating.
However, doing your due diligence before a patient is seen is essential to providing proper care. That means obtaining prior authorization in cases where it’s needed and checking the lists of required prior auths frequently to make sure your process reflects payor requirements.
Unfortunately, getting a denial for lack of prior authorization is one of those no-win appeals situations where you are better off writing off the charge and shoring up your pre-appointment process to avoid future denials.
Not Timely
Working in healthcare these days is stressful, but it’s essential to patient care that you and your staff are timely in filing claims with payors.
If you receive a denial that states the claim was not submitted to the insurance company by the deadline, appealing the matter isn’t going to be a win for you. While it is frustrating that payor submittal requirements are all over the place – from 30 days to upwards of a year past service date – knowing the requirements of all the payors you deal with is part of the care your practice provides.
Keeping a close eye on due dates from individual payors and working those dates into your claims submittal workflow, is the best way to avoid even getting denials for not timely in the first place.
Records Don’t Support Claim
While the other two situations are easily avoidable by tightening up your processes and double-checking information from payors, getting a denial for records not supporting the claim falls onto the shoulders of your clinical team. Whether the records don’t indicate evidence to support diagnosis codes given or the procedure codes, you can’t support a denied claim if the patient’s records don’t indicate it.
Preventing this type of denial in the future requires carefully checking all claims against patient records before a claim is submitted. Anyone entering diagnosis and procedure codes into a patient’s charts or summary of services must be sure the codes are supported in the records and, if there isn’t evidence to support it, the codes must be corrected.
Too many claims denied for the records not supporting the claim not only means you’re losing money on denied claims, but it can put your relationships with payors in jeopardy.
Managing claim denials is one of those annoying parts of your job, but it’s an important one to help protect your practice’s revenue and maintain patient satisfaction. Get more proven tips for getting your denied claims paid in Healthcare Training Leader’s online training, Proven Appeals Template, Get Your Denied Claims Paid Fast. You’ll receive tried and true strategies from Leonta Williams, RHIA, CCS, CCDS, CPC, CPCO, CRC, CEMC, CHONC, for appealing payor denials and help to avoid those situations where you run into no-win appeals. Access this valuable 60-minute training today!
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