2. Official Disclaimer
The information presented is for general information only and are not meant to substitute
for legal advice. Always seek the advice of an attorney on legal matters.
Legal Guidance
Copy righted © material is subject to fine of $5000 per occurrence
03

3. 04
BILL PROMPTLY
• 6% - 15%
of revenue is lost to
timely filing denials
• Your #1 responsibility is to get your bills
to the payer in a timely manner
• Bill daily – it improvise cash flow, while
making it easier to identify rejections,
denials and lost claims
• Get a receipt for your submissions – send
X, receipt for X

4. 05
You have to
press send

5. 06
In receipt of a bill a payer can only:
Pay the claim
In full or in part
Reject the claim
Deny the claim
Ask for more information
If you bill timely and are not paid within 30 days, verify on the
payer website the payer’s receipt of your claim. Not there - resubmit
In NYS & most
states, a payer has
30 days to act on a
received claim
electronically.
45 days if
submitted on
paper

6. 07
Read & Understand Claim Receipts Read &
Understand EOBs
Paid
Now that they have paid it –
have they paid it in full?
Have they paid it at the right
rate?
You need to review and audit
the claim
Rejected
They said they could
not process the claim –
something is wrong
They asked for
additional information
You need to understand
what was “wrong”
promptly correct and
resubmit
Denied
They said NO
You need to
understand why the no,
and what you can do
about it

7. 08
No. 1 Reason for a Rejection of a
claim
An error in the patient name
and/or address
• 10%- 30% of all claims are rejected
• 50% of all rejected claims are not re-
submitted
 Meaning the revenue from 5% -
15% of billing is lost
Understand, Correct And Resubmit Rejected Claims

8. 09
Top 10 Reasons for Rejections
1. Incorrect or missing patient demographics
2. Incorrect or missing ICD-10 diagnoses
3. Incorrect of missing CPT modifiers
4. Incorrect or missing CPT procedure code
5. Physician Identification missing
6. Incorrect or missing place of service code
7. Missing or incorrect number of units of service
8. Claim submitted to the wrong address
9. Duplicate claim
10. Additional information needed – request for medical records

9. 10
 Promptly correct and resubmit the claim.
 Track as you would a new claim.
 Remember: The clock is running against you – timely filing is based on the date of service –
not the date of a resubmitted claim.
Rejections Require Resubmission

10. 11
• 6%- 14% of claims are denied
• 50% of denials are never appealed
 Meaning the revenue from 3% - 7%
of billing is lost
• Never accept a denial without a challenge
• A lost appeal is learning opportunity
Denials – when they say NO

11. 12
Principal causes of denials
Lack of permission
• Requires Prior Authorization or
Precertification
• No Referral on File
▪ Set some policy
▪ Get some knowledge
• If you have it -appeal
Lack of Eligibility
• Coverage terminated
• Services Excluded or Non-
covered
▪ Trust but verify
▪ A role for credit cards
• An other insurer is primary
• Understand the basics of
COB
Lack of eligibility means the patient is
responsible – pursue the patient
It does little good trying to appeal
eligibility/non-covered issues

12. 13
10%
10%
17%
17%
19%
27%
RecoveryOn Appeal
Between 0% and 10%
Between 10% and 20%
Between 20% and 30%
Between 30% and 40%
Between 40% and 50%
Between 50% and 60%
Appeals recovery money

13. 14
• New physicians/providers
• New Procedures
• New technology
Before learning by denial – know what your in for:

14. 15
You represent that this
claim was denied for….
Attached please find
documentation that such a
determination was in error
Simple – if you have the
documentation to show they are
wrong
• Timely filing
• Lack of referral
• Lack of Authorization
While Most Appeals Are Simple

15. 16
Denials for clinical reasons require more skill
and these 4 sentences
Sentence One & Two
We request peer-to-peer conversation as sanctioned by most utilization review laws to facilitate a
complete review of the denial. A clinical peer is defined by the Utilization Accreditation Commission
(URAC) as a physician or other health professional who holds an unrestricted license in the same
specialty as typically manages the medical condition, procedure or treatment under review.
Physicians complain that “desk reviews” can never be as accurate and complete of a clinical picture
as face-to-face interaction with a patient. Physicians should set aside time to pursue peer
conversations with insurers. Such sessions are often effective in reaching a mutual agreement and,
if not, the treating physician will still have initiated important dialogue with decision makers which
could, in time, shape treatment options for patients.

16. 17
Sentence Three
If peer-to-peer discussion is not promptly provided, please provide the following information which should have been
properly disclosed with the initial denial: name of initial reviewer and description of applicable advanced training
related to this type of care, a copy of the applicable clinical or coding guidelines used in the decision and the date of
development, an outline of the specific records reviewed and a description of any additional records necessary for
your review and recommendation regarding alternative care and/or coding which qualifies for benefits.
This important sentence forces the carrier to disclose all details pertinent to the decision. Obtaining all the
elements of this request will allow you to assess the quality of the review process and will help you determine if any
other reimbursement is available or likely available for future treatment related to the patient’s condition.

17. 18
Sentence Four
It is our position that failure to provide the requested information may
violate (state name) and/or federal claim processing disclosure laws and,
non disclosure reflects a poor-quality medical review process which
discourages treatment provider input.
Remember
Health plans pay based on Coverage – not medical necessity
The services must be medically necessary to be eligible for coverage, but coverage is based on the benefits
that are purchased for the insurance premiums

18. 19
• Send appeal in within 30 days of the date of the denial
• Send a NYS DOI/Regulatory Complaint at 60 days
Appeal – Monitor - Get Help

19. 20
Those who refuse to learn from history are doomed to repeat it
Learn from denials
Do you have a higher than the
norm level of denials?
Is there a pattern?

20. 21
Never call a plan to ask the status of a claim or
an appeal
• Call centers are measured by the volume of calls they can “process”
• He said/she said
• And the she/he often times does not give a last name
• The answers may be correct, but the question may be wrong
• You suffer the consequences of their errors
Think of the IRS – telephone inquires – answers wrong 14% of the time, at service centers, answered
wrong 33% of the time, and emailed, answered wrong 35% of the time.