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Do These 5 Things When Insurance Won't Pay



We hear it all the time. What do I do if my claims get denied? This is a complicated question because claim denials are a symptom of the problem, but the issue is that the byzantine nature of insurance means that there could be a host of root causes that lead to claim denials.


Claim denials are pretty commonplace and are scary to receive. They are scary because it means that all that hard work is at risk of not reaping a reward.


Don't panic though, because there are several things that you can do to make sure that you are dealing with your claim denials in a clear system that leads to a payment from the insurance company or from your patient.





Reasons Why Claims Deny

Let's start at the beginning. Why do claims get denied?


Claims get denied for a host of reasons, but some of the more common denial reasons are:

  • Coordination of benefits

  • Incorrect CPT code

  • Incorrect ICD-10 code

  • Incorrect HCPCs code

  • Patient not found (how did they lose a patient?)

  • Session limit exceeded

  • Provider not eligible on the date of service

  • Information missing

  • Information requested by the patient not returned

  • Timely filing

  • Incorrect or missing modifier

  • Incorrect place of service code


AND these are just some of a host of reasons for why your claims are getting denied and each of these reasons has a solution or action that should be taken to bring the claim to resolution. The problem is that resolving a claim denial can take hours, days, weeks, or months to bring to resolution.


So, the key to resolving a claim denial is to have a fair bit of endurance and a clearly defined process to follow when a claim is denied. The first step in resolving a claim denial is to not panic. Understand that claim denial happens and they are commonplace when you take insurance.


Knowing that claim denial are an assumed part of taking insurance, the best thing that you can do as a clinician is to have a process to address them when they occur. The other thing that you can do is hire someone or a company to do that for you, but if you do outsource this particular process, you will want to make sure that whoever you are trusting to handle this process actually has a process and are not taking a "spaghetti on the wall" approach.


That DOES NOT work!


Here are the 5 Things to Do When a Claim Denies

  1. Read and Understand the Explanation of Benefits

  2. Collect these documents and numbers before taking action

  3. Take action

  4. Document EVERYTHING

  5. Follow-Up Regularly

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