Overcoming Claim Denials in your Practice

Asset Protection for Your Urgent Care BusinessIn the healthcare business, there are times when getting paid by an insurance payor can be a difficult hurdle to overcome.  Sometimes, claim denials can take a minimum of 60 days to be approved which can be crippling to the average urgent care physician owner.  Luckily, there are steps that can be taken to help ensure that overcoming claim denials in your practice is no impossible task.  Through planning and adequate communication with patients and insurance providers and a robust denials management program, healthcare claim denials can be mitigated for your urgent care center or ambulatory surgical center.

According to Mark Scherzer, attorney in private practice in New York City as well as legislative counsel for New Yorkers Accessible Health Coverage, the number of reasons for denial of medical claims is legion, but often falls under the main categories of not being a covered service, or not being medically necessary.

Nasir Ali, M.D., medical director of Advance Urgent Care, president of American College of Urgent Care Physicians elaborates and explains his two part reasons why a claim would be denied in an urgent care setting.

“Number one is the urgent care did not have a contractual business relationship with the insurance company that they were trying to bill.  The patient should not have been seen by that clinic to begin with because they did not participate with that insurance,” Ali says.“If someone overlooks it and goes ahead and sign in the patient, see the patient, and then submits the claim, then the insurance company’s computer and your computer don’t talk to each other.  They look at the tax ID and they say “This is not our contract so we are not going to reimburse it.”  So the claim is denied.”

Ali says the other piece to the claim denial puzzle is that although the practice participates in the network, there can be typographical errors made by the receptionist or whoever is in charge of the data entry.

“They can make a typo in patient names, if the name is hyphenated, they can fail to address that issue, or they made an error in entering the policy number or the date of birth of the patient or the principal policy holder,” Ali says.

If any of such errors are made and the information does not come in sync with the information already in the system, then the claims will be spit out by the computer, Ali says.  Ali says typos are the largest reasons for denials and can possibly be corrected up front by providing accurate information to the insurance company so that the claim gets paid on time.

Ali believes in preventing denials and at his office, patient insurance information sees numerous eyes before the “send” button is pressed on the computer.

“We have a receptionist who enters the information then there is a second person who does the charge entry.  The person who is doing the charge entry is also responsible for overlooking the information that is already there before they push the “send” button,” Ali says.

Dan Candage, Operations Director for ADP Advanced MD Medical Billing Services says that a prevention plan is paramount to a physician owner when it comes to gaining reimbursements.

“The biggest thing is understanding which payors you are participating with and which ones you are not and really understanding thier requirements up front.  That’s something an experienced billing company and rules-based practice management system can bring to the table.  This is an understanding of what payors want to see on their claims, what things they will and won’t deny,” Candage says. “You also don’t want to get stuck in a situation where you are seeing patients who are not in network and may have limited or no out-of-network benefit.  That’s going to be a problem out of the box.”

Candage advises that any good denial management process is going to involve a formal process where you look at what those issues that insurance companies are denyingand then  in order of priority, automate those things within your practice management system and build them into your front end workflows.

“There has to be a formal and proactive denial management process,” Candage says.

Ali says that sometimes it is the case that a policy may not be effective due to an employer not  paying the policy  by a certain date.

“The computer will automatically turn off the policy although you walk around with a valid card in your pocket.  Sometimes when you verify the information, if the insurance is good or not, the computer may say that it is good, but by the time the claim is sent, if during that window, the employer had not made a payment, it would be denied as “policy not in effect,”” Ali says.


What if you are still denied?

Candage says that even if prevention fails, there can still be hope for the provider based on the situation.

“We still review the denials and look down the road to see how we can avoid this in the future.  Once we are sitting with denials, we will go throughthe  process to appeal those.  It depends on the payor.  For example, Medicare will want a reconsideration form and other payors may want another special form,” he says.

Candage says his company is successful in a high percentage of denials when it was just a clerical error, though he admits it can take an additional 60 days or more before the practice sees a payment.

“Where we are less successful is with cases involving a non-covered service, where the insurance was not in network, or the claim was submitted past timely filing limits.  Those things are tougher for any billing company to recover, but where it is clerical information error, we have a very high success rate,” Candage adds that typically 80 percent of denials relate to errors made at the time of service.


A patient is the best advocate

All three of the experts claim that the patient is the first step to avoiding a medical claim denial.  This is accomplished through clear communication and a patient’s own understanding of their insurance policy limitations.

“For a lot of urgent care centers, the whole idea is that the patient walks in and is essentially assumed to be self pay. It is up to the patient to duke it out with the insurance company in order to recover the payment.  The patient should know whether it is going to be covered or not,” Scherzer says.

Candage advises patients to advocate for themselves from day one.

“Most physicians will verify that they accept your insurance and that the services you receive are covered, but you can’t take them for granted.  The patients must actively advocate for themselves.  Call your insurance company; make sure that the procedure is covered, verify if you have a deductible or co-insurance responsibility and that you are not surprised by unexpected expenses.  Good physician practices will do this on behalf of their patients to make sure that they are not stuck with a monstrous bill or are at least aware of it ahead of time to make proactive payment arrangements prior to the service ever being performed,” Candage says.


If you have an interest in learning more about the subject matter covered in this article, the M&A process or desire to discuss your current situation, please contact Blayne Rush, Investment Banker at 469-385-7792 or Blayne@AmbulatoryAlliances.com

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