Why is Your Claim Not Processing?
Updated: Sep 29, 2022
The majority of insurance carriers are mandated to deny or pay a claim within 30 days of receiving it. As a practice, you know you need to receive payment from the carrier (and the patient, for that matter) as quickly as possible. You also know this doesn't always happen. Why?
A Proactive Approach
A few proactive approach steps on handling claims denials include:
Expect payment in 15 days of a claim approval by the carrier.
Make sure you analyze the reasons for any claims denials.
Follow up with the carrier on a timely basis to obtain claim payment status.
If payments are averaging more than 30 days, develop a comprehensive process for claim follow up to improve your cash flow and accounts receivable results.
Consider following up in as soon as 7 to 10 days after submitting your claim to the carrier.
Claim not on file | Authorization or precertification | Claim pending for additional information from the member/provider | Coverage terminated | Request for medical records | Incorrect patient identifier information |Non-covered or excluded coordination of benefits | Timely filing | Need to bill the liability carrier | Missing or invalid CPT or HCPCS codes | No referral on file.
Managing Claim Denials
If you can manage claim denials (most are related to coding or billing issues) efficiently, your practice will benefit financially. Some tips to manage claim denials include:
Appeal incorrect denials via phone, refiling, or an appeal letter.
Fight the denial by submitting your appeal within seven days of receiving the letter.
Study the dollar amount of the appeal to ensure that it is financially worthwhile.
Enlist the patient for help if necessary.
Know the carrier contract terms including covered services and compensation.
Examples of questions to ask include:
What is causing the processing delay?
Why is the claim pending?
Who is the best person to talk with to address this claim?
How does this match up with the carrier contract?
What information is missing to resolve the claims issue? Who is the responsible party for submitting this? What is the deadline (if any)?
Make sure the accounts receivable team has absorbed continual updates regarding revenue cycle management such as the best ways to process claim denials while instituting a clean claim processing workflow. Make sure your front office team receives continual updates on how their workflow processes can prevent denials from the start - i.e. not obtaining correct insurance verification
Your persistent focus of preventing and resolving denied claims should result in removing barriers to receiving a legitimate payment or claims decision.