When a carrier suddenly begins to deny claims, your first place to look for an explanation is on the EOB. Every carrier will provide a reason code for the denial. Some will even tell you if the claim can be resubmitted, sent back through for reprocessing, if a new claim needs to be submitted, or if you need to begin the appeals process.

Another resource would be the carrier’s Reimbursement Policy from their website. This is the policy by which claims are processed and would tell you “proactively” what needs to be sent on a claim form in order to be reimbursed.

Do not simply write off the balance – always spend the time to attempt to get your money.

The patient must have a significant This happens more often than you might think. It’s crucial for an office to perform a verification of benefits on the patient’s behalf. Even if a patient is correct about their coverage, which is rare, your office should still complete this process. Many times, it can be done through a portal like Availity, Gateway, or others, but you should not discount even calling the carrier provider line. This step is the foundation of a great Financial Department for the office. It begins the financial relationship with your patients. Yes, it is their insurance, but it is also the responsibility of your office to verify the accuracy. After all, your office handles insurance, services, codes, etc., more frequently than the patient does.

The decision for a provider to be in or out of network with a carrier is always up to them and should not be influenced. Here are some things to consider. If the carrier will allow you to see their fee schedule prior to signing a contract with them, this would be beneficial. This way, you can see what the allowed amount will be for your services. Also, you could ask for a copy of the contract in advance. READ IT CAREFULLY. You can even have your attorney review it. You also might consider looking at being in network with the larger carriers in your area.

CAQH (Council for Affordable Quality Healthcare) is a not-for-profit collaborative alliance of the nation’s leading health plans and networks. CAQH allows providers to complete one uniform application for credentialing with over 900 different health plans. While it is not Mandatory to enroll or become credentialed in this manner, you may find that it saves time. You (the provider) must maintain your information with CAQH on a regular basis. For example: If you change office locations, have staff turn-over, or retire, it is up to you to update the information in the CAQH record.

Begin this transition by reviewing your contract with your current billing company. In most cases, there are specific reasons for terminating a contract. Next, contact your software company to determine if it meets the needs of being able to submit claims electronically; be sure that you have all of the information for each carrier input to the software and it is ready to go. Determine when your transition date will be.

Ensure that your staff is trained properly. Have all your policies and procedures in place and updated. Have a system set up in order to process denials or rejected claims and payments. If you will be using a clearing house, you will need to contact them and let them know that you are moving this process to “in house,” and they will help set up the connection with them. Submit a test claim in order to make sure that there are no hiccups in the process.

EVERY Records Request should be considered an audit of some sort. When this happens, we recommend that you first look at the reasons for the record requests. Next, visit the carrier’s website to see if they are conducting an audit of this nature. A carrier can conduct random audits or a mass audit. If the request is only for one patient, this could be considered a random audit. It could also be an indication that more information is needed in order to process the claim. If a carrier requests for multiple patients at one time, this could be considered a mass audit.

It is always better to respond to EVERY request instead of ignoring it. You can always ask for an extension if you need additional time to get the information returned to the carrier.

The foundation of a great financial (billing) department is the Verification of Benefits process. Also, be sure that you locate the Medical Review Policy (MRP) and the Local Coverage Determination (LCD) for each carrier, especially those that you are in network with. These documents contain the information for the carrier about what they want included in the documentation, on a claim form, modifiers, appeals, etc. It is like having the “play book” for the other team. Establish a system and schedule time to get everything accomplished.

If this is occurring with every carrier, you should stop submitting any further claims until you can determine what the error is. Next, are they denied or rejected? It is very unusual for ALL carriers to “deny” for the same reason in a mass quantity. It could be that they are rejected versus being denied. For example, if your software is not placing the provider signature in Box 31, this would cause all of the claims to be rejected.

Look at the denial reasons on the EOBs. Are they all denied for the same reason? This is the best place to begin to determine what needs to be corrected on the claims. It could be that you need to make a correction in your software in order for the issue to be fixed permanently.

Once you have made the corrections, then resume submitting your claims again and get caught up.

Mass denials across many carriers (if that is truly the case) could be a sign that you are being looked at for a potential audit. Reach out to the WCA for assistance, if you determine that this is what you are experiencing.

You can begin by “troubleshooting” the actual claim form. Here is a link to the NUCC (National Uniform Claim Committee) instructions on how to complete a CMS-1500 claim form: https://www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2020_07-v8.pdf

Go through every box and verify that you have the correct information populated. If that does not supply you with the information needed, then you can review the carrier’s Reimbursement Policy on their website. This will tell you what they need in order to reimburse your office, based upon what is on the claim form and what is in the patient’s documentation.

A rejected claim means that something is incorrect on the claim form that is not allowing it to be processed; for example, a signature is missing, or the patient identification information is missing.

A denied claim indicates a claim that has been accepted to be processed by the carrier, but when being processed, it did not meet the payer’s definition of Medical Necessity, which is the guideline that each carrier uses in order to determine if a claim is payable of not. You can find a carrier’s definition of Medical Necessity and their requirements for Medical Necessity on their website (most are published). If you cannot locate this on the website, you can contact the carrier directly for this information. A claim can also be denied due to errors such as missing modifiers, dates, CPT or ICD codes, etc.

The appeal process exists to be able to help offices get corrections or reconsiderations without being vulnerable. However, the information can be held in their systems and reviewed during an audit.

Every insurance carrier should have the steps to the appeal process on their website, in their policies.

Here is a synopsis of the process. Be sure to visit the following link for details: https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals

First Level of Appeal: Redetermination by a Medicare Administrative Contractor (MAC)
Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC)
Third Level of Appeal: Decision by the Office of Medicare Hearings and Appeals (OMHA)
Fourth Level of Appeal: Review by the Medicare Appeals Council
Fifth Level of Appeal: Judicial Review in Federal District Court.

It depends.

Do you have a financial statement signed by the patient? A financial statement should be signed by every patient that comes into your office for care. It should be included with the initial paperwork. It basically states that the patient understands that by signing this form, they acknowledge that they are completely financially responsible for the payment of any services provided. Regardless of Insurance Participation, Worker’s Compensation, Personal Injury, Hardship, Collections, Bankruptcy, or any other issue. The patient should sign this form every time they are a New Patient or begin a new episode of care.

Are you in network or out of network with the patient’s insurance?

If you are out of network with the patient’s insurance, you are not bound to the allowed amount (unless you are deemed as in network) and can then collect any unpaid portion from the patient. If you are in network with the carrier, then you can only collect the unpaid portion UP TO the allowed amount. Because you have agreed to accept the allowed amount as your fee, then that is all that you can collect.

If you suspect or know that service will not be covered (i.e. maintenance), then you should verify with each carrier if they require a Waiver of Liability form to be signed. This form is signed by the patient at the onset if care.

Your fees are your fees. Whatever number you determine is up to you. However, if you become in network with an insurance carrier, you will be subject to their allowed fee schedule. Some carriers will allow you to review their fee schedule prior to becoming contracted with them.

When determining where to set your fees, you should take a few things into consideration. How much overhead do you have? Often, offices that are just opening have a higher overhead than they do clientele. This is to be expected. Using the formula of overhead (maybe 6 months’ worth) ÷ number of patients (same 6 months’ worth) = your cost per patient visit. Keep in mind that both factors will fluctuate and for that reason, you will want to review this process every 6 months for the first 2-5 years of practice.

Keep in mind that you should never discuss your fees with other offices or vice versa. Nor should you discuss the amounts that you are being reimbursed by carriers. This is considered “price fixing” and is illegal.

You can change your fees whenever you like. You should refrain from making downward adjustments to your fees or raising them too many times close together. Once a year, once every 3-5 years, etc., is acceptable and usually does not put a hardship on your patients. Whenever you make changes to your fees, you should provide at least 30 days’ notice to your patients as a courtesy.