Normal thought process: “I have jumped through all the proverbial hoops, dotted every i and crossed every t, even some x and dotted j’s too… why are my claims still being denied?” Well, if this isn’t a tale as old as time, we don’t know what is. Let’s go through some steps we like to revisit to ensure our clients’ claims are approved and paid for in a timely manner.
1. Timing is EVERYTHING! Does the insurance company you’re dealing with allow you to file the claim within 30 or 90 days from the time the service is provided? Is there a filing deadline for this claim type? Always know how long you have to file a claim, as well as how long you have to file an appeal on their decision if your claim is denied.
2. Did your claim check all the boxes? Did your patient receive the necessary pre-authorization of service prior to their treatment? This is crucial for things that are not considered routine, like surgeries, hospitalization and behavioral care. If the services provided were given without proper authorization, coverage of the claim will more than likely be denied. You should, ideally obtain pre-authorization from the insurer on the patient’s behalf.
3. Claim loss and eventual expiration. So, you sent your claim, the file date was within the insurer’s filing deadline. The claims system entry date, by the insurance company, was not. They “lost” your claim within their own organization. This will be a denied claim, through no fault of your own. One way of keeping this from occurring would be calling and following up, or emailing their team, to ensure that the claim was processed within its timing.
4. Was there really medical necessity? Again, did you check all the boxes? Jump through all the hoops? Did you meet all of the criteria that this insurer deems necessary to outline your patient’s medical necessity? Yeah, but only kind of… that’s a denial. In this case the ball sometimes falls squarely in your court to prove medical necessity.
5. Covered? Coverage excess? Excluded? It’s a fine line some insurers draw when covering certain medical services like, “We only cover 25 days of in-patient treatment for rehabilitation after slip and fall from a second story.”
Okay, but the patient fell off a roof, on a one-story property, needs to be taught how to walk again after injuries were sustained to his back and legs, and use his dominant hand to write again after shattering his wrist and requiring surgery to place pins and a rod to stabilize their injury. Negotiating this, exposing the need for treatment deeper than just a cast and explaining the lasting effects that not giving proper rehabilitation takes the years of knowledge garnered by the team at Gables Medical Billing.
6. The coding was just no good. The coding is another tricky place to find yourself receiving denials. Gables Medical Billing always looks to submit a clean claim. Often times forgetting to put a modifier can be the difference between receiving a payment or a denial. In the event that you find yourself in this situation, don’t worry it can most likely be resolved by resubmitting a corrected claim. Gables Medical Billing has the knowledge and experience to submit clean claims from the beginning.
