Denial Management


Healthcare Claims Processing

Once the bill has been received by the Health insurance billing company, you do not have to be at their clemency to get paid in a timely manner.

Depending on your billing method, you should expect to receive payment in as little as 15 days. If your insurance payments are averaging a turnaround time longer than 30 days from the time your bills are sent out until you receive payment, your office needs to develop a process for claim follow-up. Following up on the status of your healthcare claims can definitely improve your accounts receivable days.

Most managed care contracts allow insurance carriers 30 days to respond to your claim without penalty of interest. That doesn’t mean they have to pay the claim within this time frame. Developing a collections policy for your medical healthcare claims can guarantee that your claims will be paid quickly. There are four reasons why you need to follow-up on your medical claims.

The claim was never received:

The biggest delay in payment is due to the claim not being on file. In other words, the claim was not received. This usually happens mostly with paper claims getting mysteriously lost. To avoid this, it is wise to send claims electronic when you can.

If the claim hasn’t been followed-up on quickly, it could be a month or longer before you would even know the insurance company hasn’t received the claim. For paper claims, allow 10 business days before calling to see if the claim has been received. For electronically billed claims, you should be able to call within 5 business days.

The sooner you are aware that the claim has not been received, the sooner you can get another claim out the door.

The claim has been denied:

Depending on the denial reason, you can have the new claim sent out way before you even get the paper denial through the mail. By calling the insurance company and finding out the denial reason instead of waiting to receive the denial in the mail, you can possibly correct the reason the claim was denied. Resubmitting the claim few days earlier than waiting for the denial in the mail will definitely shorten the turnaround time for your payment.

The bottom line is getting a head start on your denials to get the healthcare claims process moving again.

The claim is pending for information from the member:

Sometimes claims of healthcare can be placed in pending for a certain amount of time due to additional information needed from the member. Although, the insurer has probably sent the patient a letter in the mail, it would be wise for your collectors to contact him or her as well.

One reason is that by calling the insurance, you can notify the patient before the letter ever reaches them. Also, if you can get them on the phone, you can hold a conference call with the member and insurer to make sure the information is given and received.

Lower reimbursement than contracted fee schedule:

If the insurance company has already made a payment on a claim and if that payment is found to be lower than the contracted fee schedule, then this issue needs a special attention, as collectively the balance on the claims which are underpaid constitute a significant portion of the ACCOUNTS RECEIVABLE and this portion can be definitely converted into Revenue. This task could be cumbersome or complex, but an AR REPRESENTATIVE would achieve it, using his/her experience, knowledge, intelligence & skills.

Our team also reverts back to the practice with changes in the health insurance billing guidelines – as in, revising billed amounts – to achieve maximum value on contracted payments.,

When do we call patients?

• When there is no insurance coverage information found in the demographics section of the patient’s account.

• When the insurance company has denied a claim stating that the patient is not eligible for coverage at the time of service, where the date of service could be prior to the effective date or after the termination date of patient’s insurance coverage.

• When any personal info like patient’s name, social security number, date of birth, address etc is found to be incorrect in the patient’s account.

Internal Process:

Building rapport with the insurance representatives in an AR FOLLOW-UP, while calling the Insurance Company is important. Also, we need to develop a certain level of professional relationship with the Insurance Representatives. This would help us find solutions for cases where the claims have been denied consistently for various reasons including global issues. In some instances, the representatives might even turn hostile and might not even reveal much of the required information, which could prove vital in proceeding further on the claims and we have to be very careful in handling situations like this. The AR REPRESENTATIVE should have strong interpersonal & communication skills and should be able to make the Insurance Representatives feel comfortable and also should make the call easy going. Any information, which could help us find the solution for an issue, should be obtained over the call.

For instance, after a few follow up on the pending healthcare claims processing and building viable working relationship with a particular insurance carrier, the representative was able to see that the team was working on legitimate claims that could be worked on. We were asked to send a fax with nearly 100 claims and the relevant information. The insurance office worked on all the claims and reverted back with status information on fax. Working on underpaid claims the patient’s account including the demographics, claims & payments history, follow up notes etc has to be analyzed thoroughly before making a call to the insurance company regarding the status of any pending claim.

At CrystalVoxx DENIAL MANAGEMENT is not introduced to just resubmitting a claim. We have a team of experts who analyze the reason for denial, track the most common denominators and systematically work on identifying and eliminating weak links. Our collections and denial management support helped reduce rejected claims drastically.

Contact US to know how our DENIAL MANAGEMENT expertise can help you improve your medical practice performance.