March 25, 2024

6 Strategies to Successfully Appeal Denied Claims

Meet any physician, and you’ll likely receive unanimous nods on one shared woe — the hassle of dealing with claim denials.

In a recent report by KFF, out of the 291.6 million in-network claims, 48.3 million were denied — a 17% denial rate. 

That’s not all! What’s even more surprising is that only 90,599 of these denied claims were appealed.

Providers and consumers alike often hesitate to pursue an appeal as it demands extra time and resource investment, with insurers typically adhering to their initial decisions.

Despite the daunting nature of the appeal process, here are some practical tips to navigate it more smoothly and increase the likelihood of a favorable decision.

Six Tips to Effectively Challenge Any Denied Claim

Appealing a claim may appear cumbersome, yet it safeguards and secures your revenue, ensuring you receive your rightful compensation.

Here’s how to deal with a denied claim:

1. Review the Denial Letter

Dive into the denial letter to understand why your insurer rejected your claim. Pay close attention to any references to your insurance policy. Understanding the specific grounds for denial is pivotal in building a robust appeal.

2. Never Skip the Appeal Letter

The appeal letter is an imperative tool in challenging a denied claim. Avoid sending only the balance bill and an EOB (explanation of benefits). Instead, take the time to write a letter that concisely outlines your case, addresses the denial reasons, and provides supporting evidence. 

Seize this opportunity to make a persuasive argument for reconsidering your claim.

3. Verify and Rectify the Errors

Scrutinize your denied claim for any inaccuracies or mistakes. Whether an error in the patient details, procedural codes, or modifiers, promptly correcting them is vital to ensure the accuracy of your claim when resubmitting. 

4. Align Codes with Substantiating Medical Documentation

Confirm that the procedural codes align with the documented medical procedures, as this alignment strengthens your case during the appeal process.

For example, after surgery, codes are often assigned from the initial list of procedures. However, changes may transpire during the surgery, and a thorough review of the notes might unveil omitted or additional reportable procedures not initially mentioned in the summary.

5. Adhere to Timelines

Meeting deadlines is non-negotiable in the appeals process. Ensure that all required documents, including your appeal letter and supporting evidence, are submitted within the specified timeframe to avoid any procedural setbacks.

6. Proactively Minimize Future Denials

Analyze the root cause of the denials to identify error patterns and prevent their recurrence. Take proactive steps to minimize the chances of future claim denials, whether it involves enhancing documentation practices, clarifying coding procedures, or improving communication with the insurer. Stay informed about the policy updates and effectively communicate them with your internal staff.

How Glenwood Secures Payment of Denied Claims?

Insurance companies often throw a curveball with a denied claim. But, at Glenwood, we don’t just throw in the towel; we take a systematic approach to address the issue.

First, we escalate the matter to the provider’s office. Then, we initiate a peer-to-peer review with the attending physician, justifying the patient’s medical condition to the insurance company’s medical director.

The result? Our providers get the payment they deserve, and we keep things moving like clockwork.

For example, Aetna denied a claim involving CPT codes 95004 and 95024 (both associated with allergenic tests), citing them as experimental/investigational. Ironically, the submitted diagnosis (DX: J30.1 — Allergic rhinitis due to pollen) aligns with Aetna’s guidelines.

Despite the valid diagnosis, Aetna rejected two consecutive reconsideration requests from Glenwood. In response, we requested a courtesy call back from the insurance company to discuss the denials directly with the provider. During the call, the provider defended the claim, emphasizing the validity of the diagnosis. This strategic move proved effective in overturning the insurance decision, ultimately resulting in the successful payment of $23,000 after appealing nearly $29,000 in claims.

Each claim matters, and our commitment is to achieve over 99% collections by meticulously monitoring each claim and appealing denied claims until we successfully resolve them. We ensure private practices receive their rightful compensation, allowing them to dedicate more time to patient care and less to claim processing.

GlaceRCM/EMR - Billing Service For Private Practice

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