How to get unpaid claims paid

A physician cares for a patient, bills the health insurer for the services performed, and expects to get paid. But what should you do when the claim is partially paid or pended in the process and you don’t agree with denial?

While there are many claim denial classifications, they shouldn’t all be submitted through the same channel for review. It’s imperative that you engage the correct process.

Contact Your Network Representative

Depending on the health insurer, the exact title can vary for this role (network liaison, network coordinator, provider representative). Essentially, this person works in the provider servicing side of the company and has the responsibility of resolving provider concerns and offering direct ongoing support to providers. They can be assigned by specific groups, provider specialty, hospital system, geography, etc.

A provider rep can have hundreds of providers on their roster. So, the most efficient use of your provider rep is when you are dealing with a large volume of claims (500+), denials driven by a system issue, or high dollar claims that did not reimburse correctly – meaning you got paid, but not at your contracted rate.

The concerns presented to your provider rep will require in-depth investigation and will most likely involve coordination with other departments within the company. It’s not reasonable to expect same day turnaround. Once you speak with your provider rep, gauge the resolution time and confirm dates to touch base for more complex concerns.

Reconsideration Request

These are comprised of administrative denials that might call for explanation, but not require supporting physical documentation (i.e., late claim submission, claims where an authorization or referral was obtained but did not link properly to a claim). If the health insurer has a portal to submit these, use it. Otherwise, call the provider service unit or your provider representative to assist.

File an Appeal

Each health insurer will have different rules regarding how an appeal is defined, where to send the appeal, the necessary documentation to have an appeal reviewed, submission timeframes, and physician vs. hospital appeal servicing. However, there are 2 main categories of a provider appeal, billing disputes & clinical denials. Billing Disputes are commonly defined as denials or pending payments related to CCI edits, modifier application, and denials based on the insurer’s Claim Payment Policy. Clinical denials are those services considered Not Medically Necessary, Experimental, Investigational, or Cosmetic.

Consult w/ a Clinician

Most insurers have a process to consult with a clinician for pre-service, authorization denials. How often do you take advantage of it? This is an opportunity for peers to discuss the service in question and make a case for approval. At a minimum the requesting physician should have available, for both parties, the medical history, exact rationale given in the denial, and Interqual/Milliman guidelines, if applicable. As with appeals, the rules vary and you will need to review each health insurer’s guidelines regarding this process.

Submit a Corrected Claim

Use this option only to add/update a procedure code, add a modifier, or to include a description for an unlisted or miscellaneous CPT code.

Claim denials are a part of the process, but that doesn’t mean that you should always accept the denial as the final result. There are numerous ways to dispute a denial. To save time, energy, and sanity, make sure that it gets to the appropriate area for consideration, the first time.