Medical billing is an important function for the healthcare providers, helping them to recover the expenses incurred while providing treatment and care to patients. The medical billers take information from various sources especially from medical coders who give the universally acceptable alpha-numeric codes to the diagnoses, treatments, and medications and produce bills to claim reimbursements for the services provided from the insurance providers. This is a part of the wider revenue cycle management process that is used to track the revenue from patients from the time of their initial encounter with the healthcare provider to the final payment. However, sometimes the insurance claims are denied and it is required that these denials are appealed in order to get appropriate reimbursements. Appealing the denied the claims is done to be done by the revenue cycle management team at the healthcare providing organization or the RCM services providers who have been outsourced this job. Here are some best practices to be followed while appealing for such denials as suggested by RCM services experts.
Accurate billing: Usually, the claims are denied because of data entry errors which can’t be eliminated totally. It should be checked thoroughly if the claim was originally billed cleanly and accurately before appealing for the claim denial. It is common for humans to err and the most common errors are related to incorrect or missing patient information, using inappropriate modifiers, wrong codes used for diagnoses etc. So, before appealing for a claim denial, it is necessary to cross-check all these things.
Insurance provider’s contract: While entering into a contract with an insurance provider, it may be decided that some services will not be paid or paid at a specific rate. It is required on the part of RCM services providers to be aware of all such non-billable services and raise bills accordingly, at the first time only to avoid any denials.
Know the timeframe: If it is found that an appeal is definitely needed, the appeal should be done completely and accurately within the stipulated timeframe as agreed in the provider contract. Different insurance carriers have different standards for appeal timeframe which has to be understood clearly by the RCM services professionals.
It should be remembered that not all insurance claims are paid without any rejections and denials. It may happen that some claims be paid for an amount much lesser than agreed for varied reasons. Appealing is a lengthy process so, it should be used as a final resort.