Rejected receivables are receivables that have been received and processed by the payer and are considered non-payable. These claims may exploit the terms of the contract between the payer and the patient, or they may simply contain some fundamental error that was not caught until after processing. A rejected claim cannot simply be resubmitted. It is necessary to regulate why the medical billing claim was rejected.
Refusals are usually returned based on an explanation of benefits or Electronic Remittance Advice (ERA). The availability of this information allows an appropriate appeal to be written or a reconsideration request. Most denied claims can be appealed and sent back to the remunerator for processing. This process can be time-consuming and expensive, so it’s important to get as many “clean” claims as possible when you first submit a claim. This problem can also solve with medical AR management services.
What is a Denied Medical Billing Claim?
A denied medical claim occurs when a payer, such as an insurance agency, does not approve the collection of payments for a submitted claim. This can happen when a patient is being treated for a condition that is not covered by their health insurance or is considered unnecessary. In addition, the client may have exceeded coverage limits or received medical services from an out-of-network healthcare provider.
A health protection claim can also be denied because of one or more errors on the claim form itself, in any connected medical records or documentation, or even in the billing records. In these cases, the claim may be denied rather than denied. Rejected claims cannot be appealed. Rather, they must be corrected and resubmitted by your practice or client. The health insurance company can still refuse them.
Optimize and Submit Your Medical Billing Claim Appeal:
The first and most important practice is to apply to an insured event to the insurance provider, only after a careful external review and adjustment. Submitting a claim appeal with the same errors that conduct the denial will result in another denial and no income.
You must clarify all specific details of the claim, including:
- Medical records must be accurate and appropriate (see other best practices).
- Diagnoses must be precise and fully supported by medical documentation.
- Current Procedural Terminology (CPT) codes must be 100% accurate.
- Explanation of Benefits (EOB) must be accurate and must match diagnoses, CPT, etc.
- All transformers and special conditions should be double-checked for accuracy.
By focusing on appealing an informed and active decision, you ensure it is error-free before you send it to the payer.
Missing or Incorrect Information:
We are all human and make mistakes. That’s why it’s important to double and triple-check medical claims information. Sometimes a claim may be rejected because it is missing information such as a service code. However, it is also usual for claims to be denied because the information was undertaken incorrectly. Typical examples are misspelled patient names and incorrect entries of subscriber IDs.
Review Your Policy and Paper Work:
See the performance overview in your insurance documents. The paperwork must state what it covers. It must also list limitations or barring, which are things your insurance won’t cover.
Then read the letter or form your insurance idea sent you when it denied your claim. The letter should tell you how to attract your health plan’s decision and where you can get help starting the process.
Ensure Relevant Documents are Error-Free:
Not only is it important to perfect the claim letter you send to the payer, but you also need to make sure that all relevant documentation and reporting are completely error-free. Furthermore, you must account not only for errors by your internal team but also for missing or inconsistent information in all records received from other physicians and stakeholders.
Many of the errors associated with denials, as noted above, are related to CPT codes. The most usual of these errors, following to one industry expert, include inconsistent or inappropriate coding (procedures, diagnoses, etc.), outdated codes, or lack of specificity. Most importantly, make sure all codes exactly match existing medical records.
Everything that appears on your bill – such as any codes – needs to be backed up with relevant medical records. Anything that is coded but doesn’t have proper records to back it up can be a deck for a medical billing claim denial. If the error quite exists in your appeal, you will not be successful.
Submit an Internal Appeal:
You are now ready to file an internal appeal directly with your insurance company to ask them to reconsider your case and reverse the denial of coverage. So, You can explicate the error and even ask for a full review. You will need to complete all required forms and write an appeal. The letter should include:
- What service was denied and why.
- Your claim number.
- Why your claim should be rewarded, with supporting evidence from your plan’s policy documents.
- An overview of your medical condition and details of why the service is medically necessary.
- Supporting verification such as medical records or a letter from your doctor.
You may feel frustrated and angry, but you should write a simple letter that gets straight to the point. Keep your emotions out of the letter and clearly explain why you should be covered.
File an External Appeal:
An independent organization will review your medical billing claim and make a final decision. The insurance company must comply with this decision.
- You can file an external appeal if:
- A denial involves a medical decision where your healthcare provider disagrees with the insurance company.
- The denial includes treatment that the insurer believes is experimental or investigational.
- You’re EOB or your most recent claim denial will tell you how to contact an independent review organization to file an appeal.
Conclusion
There are a variety of reasons for claim denials and prior authorization denials. Several are due to mistakes, some are due to coverage issues, and some are due to misfiring to follow steps needed by the health plan, such as prior authorization or step therapy. If a health plan denies a claim or request for prior authorization, the decision may be overturned when additional information is provided to the health plan or after a successful appeal.