Denials – Alex Yarijanian

1-Minute Pro Tip: How to Handle Claim Denials from Private Insurance Companies

Before challenging a claim, examine the reason for your denial. The reason for the payer’s denial can be found on the Explanation of Benefits or EOB. In some cases, the denial may have been caused by a clerical error such as an incorrect CPT code, a missing signature, or another simple oversight.

A denial of coverage because a PA performed the service is usually phrased as “service only covered when provided by an M.D. or D.O.” or “physician assistants not considered authorized providers under the plan.” In some cases, first assisting at surgery claims are denied for incorrect use of modifier codes (Do not assume that all companies use the same code; some use -AS, some use -80, -81, or -82.) and in other cases, those claims are denied because of the use of a restricted code or for performing a surgery not necessarily requiring a first assistant.

You may need to contact the insurance company to find out what modifier should have been used and, in some cases, you may need documentation that a first assistant was medically necessary for the surgery. Insurance companies strive to (1) retain their subscribers, (2) maintain or increase their market share, and (3) keep a positive corporate image. If the insurance company made the coverage decision and you believe that the coverage decision was unfair, enlist the help of the patient and, if applicable, the business that pays the insurance plan’s premium. Their dissatisfaction is

Sample Letter: Enlisting Patients Assistance for Claims Payment

Enlisting patient assistance in health insurance claims payment issues.

Date

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RE: Outstanding Health Insurance Payment

Dear Patient:

I am writing you concerning an issue that has arisen between [ patient’s insurance carrier ] and our office concerning payment for the services provided to you on [ date of service ].” We have made all reasonable attempts to collect from your insurance company and have not been successful.

PATIENT MESSAGING

[Explain the reason the plan has given for not paying you, or not paying you on time. Stick to the facts. Tell the patient you’re puzzled by the plan’s contention, and that you would appreciate their help in resolving any issues. If the plan’s policy is that the patient is ultimately responsible for the full cost of care, state that.]

We would appreciate your assistance in resolving this matter by:

Calling your insurance company directly and asking that the claim in question be paid immediately; and,
By asking your employer’s human resources staff to intervene.

Should you or your employer have any questions, please do not hesitate to contact our office at [practice contact and telephone number].

Thank you very much for your assistance and we appreciate your continued business.

Sincerely,

c: [ Name of Insurance Carrier ]

Don’t Lose Revenue With an Outdated Fee Schedule

If you have not updated your practice’s fee schedule for several years, you may be in for some surprises. Carenodes Advisory recommends that you analyze and update your fees annually to make sure they are higher than insurance allowables.

Remember, insurers typically will pay you either their allowable or your fee – whichever is lower. By charging less than the allowable, you are not getting the maximum reimbursement you are entitled to receive. If you are receiving 100 percent of your billed charge from a managed care plan, this could indicate your fee is set too low.

Many commercial plans base their fees on Medicare reimbursement, making it easier for you to evaluate their reimbursement patterns. As Medicare publishes its new fee schedule each year, you have an opportunity to compare your own fees against the new rates. At the same time, you can make revenue projections for the coming year and assess the value of your managed care contracts to your practice.