As a medical provider, you rely on your medical billing service to handle the insurance claims your patients need to pay for the services you provide. Both sides — you and your patients — deal with different aspects of this process. When everything goes right, it’s a process with a defined outcome: your patient receives the service and you receive the payment from their insurance with little effort on either part. Let’s chat denials and appeals.
Unfortunately, it’s not something that always goes exactly as planned. Insurance may deny the claim for any number of reasons, including mistakes made on the paperwork or the services falling outside the scope of what’s covered.
Mistakes on paperwork
Let’s start with the first scenario: mistakes on paperwork. These scenarios are often simple mistakes that prove costly and frustrating for the patient. When you and your billing service work well together, these mistakes become less common. These mistakes include misspelling the patient’s name or not being completely descriptive when it comes to the services provided. Coding issues also create denied claims; fortunately, we at Catalyst are continually training on new billing codes to help ensure your patient’s claims are coded properly prior to submission. The symbiotic relationship between you and us reduces the likelihood of these mistakes, helping eliminate the possibility of insurance denying coverage for these reasons.
What happens when the insurance decides to deny coverage because of something else? Each insurance plan has a detailed list of benefits and services it will cover, some with various caveats. For many patients, this detailed list becomes confusing. When insurance denies a claim, the patient has a few courses of action they may take to help fight the claim and receive their benefits.
There are three timeframes for insurers to provide a detailed report of why they denied the claim: Prior authorization; services received and urgent care cases. The insurer has 15 days when seeking prior authorization for a treatment they know is coming up, 30 days for regular medical services already provided and 72 hours for urgent cases. The insurer must expedite the review during urgent cases.
The patient has 180 days to complete the request for an internal appeal, but they need a list of forms to do so. They must keep all records of the services you provided, an explanation of their benefits, notes and dates detailing conversations between you, their provider, and the insurance company, and various other documents related to their insurance and services. The insurance company has 30 to 60 days to complete the appeal depending on what type of service, at which time a decision is hopefully agreed on.
As your medical billing service, Catalyst takes on the responsibility of handling medical claims denials and appeals. We work with all three parties involved to come to the best resolution possible, allowing you to continue doing what you do best: helping people! We know the ins and outs of medical claims and insurance company tactics, allowing us to provide benefits to the provider and patient.