General Reasons for claim denial are as follows:
Under coding or Up coding medical claims.
Improper usage/non-usage of Modifiers.
Not meeting medical necessity.
Improper verification of eligibility and benefits etc.
"Following diagram shows the general reasons for denials with approximate percentage of each reason."
Our staff has a good understanding of the above, contracts between payers and providers.
We interpret, analyze and identify systemic underpayments by payers at the individual claim level.
We do consistent, personalized, courteous follow-up on all accounts with outstanding balances.
We do have excellent AR follow-up skills to call upon payers, enquire about the correct reason for denial and work as per their clarification and getting the claim paid.
This entire process involves following up on underpaid claims, understanding the reasons for underpayment, and then recovering revenues from the payers by taking steps to address those issues (resubmitting claims, appeals, etc.)
We have a system to time appeals submitted and ensure that no time is wasted in the appeal process. We also develop standard appeal letters that can be easily customized with information about the particular patient and situation involved in every denial.
If an insurer routinely down-codes claims, we appeal for the code that was submitted originally and include supporting documentation.
If an insurer consistently refuses payment for a certain code, we request the physicians to contact the insurer, discuss the situation and bring along supporting documentation instead of sending more appeals.
Before signing any contract with a payer, we request the physicians to make sure that the claim appeal process is explained clearly. This helps us determine steps to be taken after a denial and consider steps for further action.