Medical billing - Denials type and way to handle them with team effort. Working on all denials with in 48 hours give better result

1. Denial Management

2. Learning Objectives and Goals:
• Identify the most common
reasons for claim denials
• Define a claim management
process to implement into
your practice
• Understand claim appeals
process for contracted payors
• Effectively utilize the tools
provided to help in the
process

3. Most Common Reasons
for Poor Claim Management
• Incorrect or inadequate demographic information in
patient registration
• Non-timely entry of changes in address or insurance
information
• No copies of insurance ID cards in the medical record
• No insurance follow-up procedure
• Lack of communication between front office and
business office
• Inadequate number of staff or not focused on the task
• Lack of knowledge of Payor claim filing process

4. How to Solve the Problem

5. What is a
Claim
Management
Process?

6. Patient
Registration
Charge Capture
Charge Entry
Claims Processing
Claims
Follow-up
Claims Appeal
Payment Entry
=

7. Benefits of a claim management process
• Increased Staff efficiency
• Increased number of
claims submitted
• Reduced number of
claims denied
• Timely and accurate
payment from the payors

8. Components of an
effective Claim Management Process
Front Office Staff
Registration
Step 1: Collect patient demographic and
insurance information using a Patient
Information Form when patient calls to
make an appointment.
• Identify the specific reason for the visit
• Make sure to record the patient’s full name as it is spelled on their
insurance card

9. Components of an
effective Claim Management Process
Front Office Staff
Step 2: Verify patient’s insurance benefits
using an Insurance Verification Form.
• Many payors allow you to check benefits online
Step 3: Notify patient of benefits and
payment expectations before the
appointment.

10. Components of an
effective Claim Management Process
Front Office Staff
Check In
Step 4: Make a copy of patient’s
insurance card. Make sure
forms are completed and signed by
patient. Collect patient’s copay and
past due balances. Have the patient
sign a Payment Responsibility Form.

11. Components of an
effective Claim Management Process
Physician & Clinical Staff
Clinical Documentation
Step 5: Document in the medical record the
patient’s history, symptoms, diagnosis, and
treatment plan, including tests that are ordered.
Step 6: Document the appropriate ICD-9-CM
and CPT codes on the super bill that apply to
the patient encounter.

12. Components of an
effective Claim Management Process
Practice Staff
Check out
Step 7: Schedule next appointment and collect any
additional monies owed by patient.

13. Components of an
effective Claim Management Process
Billing/Collections Staff
Coding Verification
Step 8: Verify and review the codes provided
to ensure they match the documentation in
the medical record and enter into the system.
Claim Generation & Submission
Step 9: Generate claim, review again for accuracy, and
submit to insurance company according to guidelines.

14. Components of an
effective Claim Management Process
Billing/Collections Staff
Claim Follow up
Step 10: Follow up with the health insurance company
after the claim is submitted to ensure that it was
received.
Payment
Step 11: Verify that payment is received in accordance
with prompt payment law and the prompt payment
provision outlined in the contract with the Payor.
Appeal
Step 12: Appeal the claim according to the payor
guidelines.

15. Appeal Process
Tools

16. Top Reasons for Denials
• Invalid patient
information
• Eligibility
• No referral or pre-
authorization
• Timely Filing
• Duplicate claim
• Invalid diagnosis or
CPT code

17. Appeal Letter Templates
• Denied for Timely Filing
• Incorrect Reimbursement
• Denied stating Out of
network provider
• Request for Recoupment
denial to payor
• Prompt Payment request
to Payor
• Patient notification of claim
denial letter

18. Track Claim Denials
• Run Monthly Reports
• Review the EOB
• Identify the Payor’s basis for the denied; delayed or
partially paid claim
• Gather supporting documentation
• Review Payor Appeals Process- send the
appropriate appeal letter for the denial
• DOCUMENT! DOCUMENT! DOCUMENT!
Use a tracking device-Claim follow up log
• Get the member involved-send notification letter
and copy of appeal letter
• Continue to appeal
• Contact employer
• Contact Department of Insurance

19. Claim Denial Tools
When payment has not been received…
• Verify that the claim was received
• Send Prompt Payment appeal letter to
Payor
• Document the issue and follow up in 10
business days. If payment has not been
received, contact payor
• If no resolution is made after second
attempt, contact the LRPHO.

20. Review Appeals Process
for all Payors
Payors with specific Appeal Guidelines or Forms:
• Aetna
• Cigna
• United Healthcare

21. Claim Appeals
Tips:
• Call first-many issues can be resolved
over the phone
• Always get a reference number
• Document the name of customer service
representative
• Fax instead of mailing
• If mailing send certified return receipt

22. Remember it is a TEAM effort!
Individual commitment to a group
effort – that is what makes a team
work, a company work, a society
work and a civilization work.

23. CLAIM DENIED FOR ELIGIBILITY
• Check paid claims in PMS.
• Find which is other active insurance
• Check any notes available General
comments
Information need to collected
• Date of denial
• Effective/ termination date of coverage
• Which is primary insurance
• Claim #

24. CLAIM PENDING FOR ADDITIONAL
INFORMATION
• Details of Missing info
(Provider/Patient)
• Processed date
• Claim #
• Fax # to send the missing
info.

25. CLAIM FORWARDED TO THE PAYER
THE PRICING CENTER
• Which is the pricing Center/payer
• Claim Processing Date
• Allowed amount and Claim #/ Tracking #
• Date of forwarding of claim to the
payer/TPA
• Payer/Processing center phone number.
• Processing time to release check.

26. CLAIM DENIED FOR TIMELY
FILING
• Date when we filed the claim
• Date on which they received the claim
• Date of denial
• Verify timely filing limit
• Check the Proof available
• Confirm What kind of Proof they will accept
( Screen shot/ Ecom Proof)
• Appeal address/ Fax # (Attention)
• Appeal limit.

27. CLAIM DENIED FOR NON COVERED
SERVICES
• Details of the non covered service like Why
this service is non covered.
• Is it as per patient policy/provider contract
• If Provider Contract- Policy for non covered
• Can we appeal (Appeal details)
• If Patient policy - Check if patient can be
billed
• Date of Denial, Claim #

28. CLAIM DENIED FOR PRIMARY EOB
• Check Claim – Primary/ Secondary
• If Primary:
• Check the paid claims & find the insurance details.
• Prim: Insurance may not be primary
• Which ins is primary & from which date onwards they
became as secondary.
• If Secondary
• Fax # and Attention – to send EOB
• If Fax is not accepted – Address where to send the
EOB.

29. CLAIM DENIED FOR COB
• Check the paid claims in PMS.
• Date of denial
• Information of the other insurance if they have on
their file
• Date on which they send letter to patient
• Claim #
• Ask them to send one more letter to patient
• Bill the patient (– As per project Specifics)

30. CLAIM DENIED FOR CAPITATION
• Claim processed date
• When they paid capitation amount to
Provider.
• If possible date of Capitated contract
• Request for Capitation Roaster.
• Confirm is it based on Patient/service
• If service confirm your service covered in
this contract.

31. CLAIM DENIED FOR NO REFERRAL
• Why they require Referral
• Patient plan details
• Check other paid claims in PMS.
• Date of denial
• Check if there is any referral on the software
mentioned for the dos
• Check if provider is participating
• Fax number to send referral.
• Claim #.

32. CLAIM DENIED FOR REFERRING
PHYSICIAN
• If this Service require Referring Physician.
• Date of denial
• Ask if provider is the PCP (ref not
required)
• If not ask for PCP’s name and phone
number
• Claim # , Appeal details
• Contact PCP ( As per your project)

33. CLAIM DENIED FOR INCORRECT
PROVIDER #
• Date of denial
• Which is Correct provider # & # in the claims
form.
• If correct send for Review ( Reference # )
• Check PMS if correct refile the claim.
• Claim #

34. CLAIM DENIED FOR INCORRECT
DIAGNOSIS
• What is DX insurance received & what
we billed
• Which is correct DX.
• Check when this DX code is Deleted.
• Which is alternate DX
• Date of denial
• Claim #

35. CLAIM DENIED FOR INCORRECT
MODIFIER
• Which modifier in insurance/ PMS
• Which is the Correct modifier
• Date of denial
• Claim #
• Move to coding review ( Project
Specific)

36. CLAIM DENIED AS PRIMARY PAID
MAXIMUM
• What is coinsurance amount & Allowed amount in
primary.
• What is secondary Allowed amount
• If Allowed amount is less than primary amount
• Check which is secondary insurance
• If Commercial – Bill the patient
• If Medicaid – Send to write off (Project Specific)
• Claim #

37. CLAIM DENIED FOR PRE-EXISTING
CONDITION
• Pre Existing – Patient/Provider
• If from Provider
• When they send Questionnaire
• Request for one more Questionnaire – fax
• From which Month they require Medical records.
• Medical records - our provider / other Providers
• If other provider
• Bill the patient (Project Specific)
• If from Patient
• When they send letter to Patient.
• Request one more letter to patient
• Date of denial
• Claim # (Appeal Details)

38. CLAIM PAID TO PATIENT
• Check the reason-why paid to patient
• Provider may be non par/Accept Assignment not given.
• Check if provider is participating
• Check the Payment details
• Date of processing
• Claim #
• Bill the patient – for the Entire charge
amount

39. Thank
You!