How to Work a Denied Claim
Main Points
Be patient and understand that this is part of the process
Documentation is the key to successful claims resolution and working the claims
Denied claims occur for a host of reasons. Find the root cause of the denials and fix those to limit the amount of denials that you receive.
Receiving a notification that you have a denied claim is the worst! A denied claim means that all that hard work that you put into treatment and administrative work is in jeopardy. Receiving a denied claim can feel like all the work that you put into setting up your business and education are for nothing.
But don't worry! Fixing and resolving a denied claim are very doable goals. In fact, most denied claims get resolved by either the provider or the patient at one point or another in the process.
Getting to the actual work of fixing a denied claim can take some scheduling and coordination, but once you have set aside some time to really look at and dig into the process, you can find that following these steps will help to lead you to claims resolution!
Be patient and understand that this is part of the process. Every provider that has rendered mental health services and billed insurance understands clearly that denials and denied claims are part of billing insurance.
Here are some things that you can do to calm down when you receive a denied claim:
Take a few breaths.
Walk around the block.
Pet your dog or cat.
Watch a YouTube video.
Most importantly, don't stress about this process. This is a normal experience and you can take very practical steps to resolving the claim. It is understandable that you would have stress or anxiety around this part of the process especially if your patient needs treatment.
Receiving a denied claim can feel like the insurance company is trying to not pay for your services.
Understand that insurance companies make mistakes as well around claim submission and they can be faulty at times, so it is your job to know the process of resolving a claim and making sure that you are paid for your services by the insurance company.
Here are some things you will want to avoid doing in order to have a better experience resolving your claim:
Yelling at your biller
Yelling at the insurance representatives
Throwing away your EOBs
Avoiding the issue completely
If you follow the next few steps you will find that resolving claims can be less painful or pain free!
Documentation is the key to successful claims resolution and working the claims. Before you begin working on your claim denials, you will want to compile the following documents or pieces of information:
The patient's insurance ID card
The patient's demographic information like: full name, DOB, address, city, state, zip, SSN
The Explanation of Benefits
The Electronic Remittance Advice
The insurance company's phone number
The address or payer ID that you sent the claim to
An original copy of the claim that was submitted to the insurance company
The claim number of the denied claim
A pen of payer and a pen to write with or your computer to take detailed notes
After you have these items compiled, you are ready to call the insurance company or start to resolve the claim denial. In most cases, you can solve a claim denial simply by looking at the information on the claim vs. how it should have been submitted.
However, if the claim was denied and all of your information on the claim was correct, and you know that you are an in-network provider for that insurance plan, then you can call the insurance company.
With the complete list above, you will have everything that you need in order to successfully resolve your claim denial.
Once you call the insurance company, you will likely have a menu of options to select from. You will want whatever option gets you to a provider representative as quickly as possible.
Once you get a person on the phone, you will want to explain to them very clearly what the problem is and see if they will reprocess the claim.
The provider representative on the insurance company's end may ask you clarifying questions. BE AS SPECIFIC AS POSSIBLE!
This will help the representative to assist you quickly. After a back and forth conversation the representative will likely give you a determination on the claim and give you a reference number.
You will want to save that reference number for future use!
Denied claims occur for a host of reasons. Find the root cause of the denials and fix those to limit the amount of denials that you receive.
Denials don't just happen randomly...very often! They occur because of very specific reasons, most of which have to do with the patient and not necessarily the provider.
Denials occur when a patient hasn't paid a premium, or when a provider is out of network. Denied claims occur when a patient has two insurances but only give you one, or when the provider doesn't properly code the sessions.
There are a host of reasons, so it will be important for you to suss out what the root cause of the denial is or was and fix that problem.
Here are some tips to help you resolve the root cause:
Ask "Why" 5 times. This technique actually comes from the LEAN methodology of process improvement. Most root causes can be found by the 5 Why process.
Do what you need to do to contain the problem. You don't want the organization to continue bleeding if there is an issue. Contain the problem as best you can so you can fix the problem
Plan what you need to do to fix the problem or implement a corrective action. Make a permanent change to the process in order to stop the issue.
Once you think you have implemented the changes to stop the problem, you will want to monitor the situation to see if it escalates further.
Working denied claims can be challenging, but it can also be a fun puzzle to solve. A lot of providers feel anxiety about this process because it can be confusing and seem like a maze.
However, if you are able to calm down and see the process as an exercise in solving the payment puzzle, it will go much faster and much less painfully than you might think.
If you are still having problems solving your claims processing issue, then give us a call or reach out through the website and we would be happy to troubleshoot your problem with you!
