Insurer Denied? Here’s What to Do

Today we offer concrete steps to battle commercial insurance denials.

It’s a common occurrence – the billing department carefully verifies who the payer is and sends a properly executed claim to the insurer. Instead of the expected payment, the payer sends an Explanation of Benefits showing the claim denied.

It’s frustrating. Many billers will call the insurer and try to resolve the issue by phone. This approach results in lots of time spent on the phone, sometimes being bounced from representative to representative and still no payment. Subsequent calls to the payer may indicate that a record of the first call was never recorded and the biller must go back to square one to follow-up on the unpaid claim.

Other times, the billing department skips the payer and goes directly to patient billing. There is much competition for patient dollars; getting a share is difficult. Furthermore, if this was a covered service, it makes little sense to pursue the patient if the payer should have paid.

There is a school of thought among some billers that by billing the patient, they will enlist the patient’s aid to resolve the claim. Yes, it is possible the patient will intercede with the payer and attempt to help the ambulance provider receive payment. But again, there are many providers billing patients. It can be difficult to have your “voice” (the bill) heard above the din.

So, what can be done? Use the payer’s own process to appeal the claim – a process that does not involve the billing staff spending extended time on a phone call. For example, Aetna has a “Practitioner and Provider Complaint and Appeal Request Form” whereby they will consider appeals. It is a formal process that has an address and a fax number to submit an appeal. The Aetna form says that filing the form is mandatory. Aetna’s web page notes which states are not included in this process because of their own state-specific standards.

United Healthcare has an administrative guide for “Claim Reconsideration, Appeals Process and Resolving Disputes.” The UHC guide discusses how to appeal denials on paper, the phone or online. In addition, it outlines the timely filing limit for appeals and how to deal with multiple claims (20 claims or more).

Cigna outlines their appeals process and provides forms for appeals on their Cigna Appeals and Disputes Policy and Procedures page. Like Aetna, Cigna discusses which states are eligible for this method of appealing claims denials.

The best approach to appealing denials is to know the payer’s system for appeals. Billing departments will send claims to over a hundred payers in a year. But daily, there are usually only three or four payers where the billing department submits claims (in addition to Medicare and Medicaid). This means that it is not difficult to learn the appeals process of the three or four payers the billing department works with daily.

Go online. Look for the appeals process or appeals form of the payer who needs follow-up. Then use that process. If there is an escalation option available, exercise it if needed (should be claim deny on appeal). Remember that some states have their own rules regarding appeals and timely filing. Therefore, check the state website where the transport originated to better understand that state’s rules.

Billing today is time-consuming. No biller can afford to spend time on a task like phone calls to a payer which may be not successful. Going to the patient is not always fruitful either. Instead, investigate the tools available from the payer and use them to your best advantage.

Maggie Adams is the president of EMS Financial Services, with over 25 years’ experience as a business owner and reimbursement and compliance consultant. Known for a practical approach and winning presentation style, Maggie has worked with medical transportation providers and billing companies of all kinds to provide auditing services, assess their billing for best practices and support their billing and documentation training efforts.