How To Appeal Denied Claims

Anthony Poggio, DPM

Even if the monetary totals at stake are small, denied insurance claims can add up and negatively impact your practice. This author provides pearls for ensuring your denied claims receive payment, offering insights on dealing with insurance companies and the importance of thorough documentation.

Denied claims can be very frustrating as it requires time and money, not to mention a great deal of antacids, to appeal a claim. Often when the dollar amounts are small, it may not appear to be worth it as an appeal can be a net loss even if you win the case.

   Accordingly, I’d like to offer some helpful suggestions to develop an office protocol that might make this process somewhat easier.

   Proper claims processing protocol should include using up-to-date billing information such as the latest edition of the CPT, ICD-9 and HCPCS coding books as well as any other manuals that insurance companies may provide. There needs to be a clear handoff from the provider (superbill) to the biller (transmission of the claim form) and on to the insurance company to make sure this process goes smoothly.

   Start with the simple things. Make sure there are no transcribing errors. For example, perhaps the biller used codes that were not listed on the superbill or used codes that were undocumented in the chart. One must properly match CPT/HCPCS codes with ICD-9 codes as a mismatch could be the source of the denial.

   The correct use of modifiers is very important when submitting claims. Obviously, using the incorrect modifier is a problem. However, sometimes offices add modifiers when there is no need for them, thinking that the more the merrier or that adding a modifier cannot hurt. This also could result in a claim denial as the carrier’s computer cannot handle an unwarranted modifier. If you are unclear on the proper use of modifiers, take steps to better understand what modifiers to use.

   Also look for technical issues. Make sure your electronic system is compatible with the insurance company’s software. Make sure that what you transmitted is what the insurance company received. There are multiple glitches that can occur in the electronic transfer system. Most insurance company claims processing software should follow a standard language. However, if what you billed does not match up with what the insurance company processed, verify what the practice sent to determine which end of the transmission has the problem. If there is a transmission discrepancy, you should check with the insurance company’s IT department as well as your own software vendor.

   For paper claims, make sure the information typed on the claim form is properly aligned on the lines and within the boxes on the claim form. If it is out of alignment, then the scanners that insurance companies utilize may not accurately pick up the information.

   Make sure your staff has filled out the claim forms, either paper or electronic, properly and completely so they list all the information that is required. Some technical errors include simple transposition of letters and numbers, fields left blank, and mismatches between the place of service and evaluation and management.

Pertinent Pointers On The Initial Investigation Into The Claim Denial

When a claim or authorization request has been denied, a designated person should take ownership of that denial. First, one needs to research the claim to see if there is an error on the part of the office, either due to the doctor or staff. If your investigation has determined that it is your error, there should be office protocols in place to identify and correct any office-based error.

   Although claim denials have an obvious negative connotation, this is an excellent teaching opportunity, creating a more positive spin to this situation. This will create a more harmonious office situation rather than always setting a negative tone. Do not stick your head in the sand. If you do not address the denials head on, then the errors (and associated expenses) will continue.

Add new comment