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Rejections and Denials – Ask a Biller #9

After eight insightful episodes, the Ask a Biller season finale is here! In Episode 9, Dylan and Maggie share key information on how to manage rejected claims. Special guest, Barbara Griswold, therapist and author of Navigating the Insurance Maze, stops by to provide valuable tips on what to do when your claim is denied. See the full episode above, and read the transcript or download the slides below.

See the full transcript here (scroll to read):

MAGGIE: Hi and Welcome to Episode 9 of Ask A Biller, the season finale! My name is Maggie, I’m a revenue cycle specialist for our in-house medical billing service– SmartBilling Pro

DYLAN: And I’m Dylan, the SmartBilling Pro manager. Thank you all for watching our videos over the last year, we hope you learned a lot. Today we’re going to be covering a topic that anyone working in medical billing knows all too well.

MAGGIE: Denials and Rejections!!! Now, some of you may be experiencing shortness of breath just from hearing those two words. Luckily, we have a segment from the amazing Barbara Griswold—a Licensed Marriage and Family Therapist, author of Navigating the Insurance Maze, Private practice owner, and overall insurance guru.

DYLAN: So, take a deep breath, and bear with us as we walk you through what to do when your claims are denied or rejected.

MAGGIE: The first thing that we want to clear up for you is what it means when a claim is rejected vs. when it’s denied. These are two different statuses in the claim lifecycle.
If a claim is rejected that means an error was caught early in the claim’s lifecycle. It usually means that something on the claim form was entered incorrectly and the claim isn’t accepted into their system for adjudication. This could be an incorrect name, date of birth, address, ID number, etc.

DYLAN: On the other hand, if a claim is denied it means that the claim has been entered into the payer’s system, was reviewed by their claim department, and payment has been denied. A denial reason could be similar to a rejection reason, incorrect demographics or inactive coverage, etc. But the distinction between denial and rejection is important because it dictates how you should try correcting the claim.

MAGGIE: For a rejected claim, you may not be able to call the payer’s claim department to get more information since it could have been rejected at the clearinghouse level. The best thing to do in that case is check to make sure that what you recorded in the client’s insurance information matches exactly what is on the client’s insurance ID card. If everything adds up, you will want to verify that the client’s coverage is still active or check with the client to see if there’s been any changes in their coverage. It’s also possible that you didn’t select the correct electronic payer ID and you need to submit the claim to a different address.

DYLAN: The distinction with getting these claims to reprocess is that you can usually resubmit the claim as an original– not as a corrected claim. With denied claims, you usually have to submit any new attempts to have the claim processed as a corrected claim– otherwise known as a resubmission. To do this, mark box 22 on the claim form as a resubmission and be sure to include the reference number from the claim that was initially denied.

MAGGIE: And now, we’re going to give the floor to Barbara to tell you her tips for resolving denied and rejected claims for her practice —


BARBARA: Hi I’m Barbara Griswold. Thanks for joining me today as we talk about denials and denied claims.

The first tip is to go after it. So many of us therapists don’t go after a denied claim. However 67% of denied claims are recoverable.

Check the explanation of benefits to see if you can get any clues as to why the claim was denied. The EOB is something that you may have to go into the insurance plan portal, or sometimes it comes to you in the mail. It will tell you how the claim was processed.

The next tip is to call the client, if you can see that it has something to do with eligibility. Or, you should call the plan. Allow 20-30 minutes for the phone call, as it may take a while to figure out who to talk to and to look up the claim. Use the phone number that’s on the client’s card. It could be customer service, so try to get to the claims department. Be ready with all the card information, your client’s date of birth, your tax ID number or NPI, information from the claim about dates of service, and how much you billed for that claim.

Another tip is document everything. That’s key in our profession, but especially in these phone calls. When did you call, what were you told, what’s the name of the rep, and the confirmation number if they give you one.

There’s a few possible call outcomes: 1. They reprocess the claim. That’s the one that you hope for. Ask how many days to allow, and schedule a follow-up if you don’t get payment by that date. 2. You need to resubmit the claim and correct something on it. That’s called a corrected claim. Ask them if you can fax it, ask for a direct fax number. Or consider mailing it to them and add a post-it note that says it’s a corrected claim.
3. Ask for a supervisor. If you tried everything with the person on the phone, ask for a supervisor. You can’t ask for one until you’ve dealt with a claims representative.

Say you’ve done all of this, and you’re still not getting what you need, the next option is to file an appeal. Ask on the phone where to send it and what to include.

If you’ve tried that and been denied, take it one step up and contact the state. The good news here is, depending on the state, usually over half of these are settled in the therapist’s favor. I’ve done this twice, and both times they were settled in my favor. Appeal to the state department of insurance or the state department of healthcare, and sometimes you can request an expedited review if necessary.

The final tip is to get help with this process. SimplePractice has an in-house billing service called SmartBilling Pro that helps you with denials and appeals. Also your professional association can help you. Also, I can help you! That’s part of the service that i provide—consultations to therapists who are having trouble getting claims paid.

I hope you found this helpful, and let me know if i can assist you and your practice. My website is www.theinsurancemaze.com. Check out my books and webinars and other resources, or contact me for a consultation.

DYLAN: Thanks Barbara, those were some really great tips

MAGGIE: One point that we want to emphasize is, like anything with insurance, working denials and rejections can take time so it’s important to be patient and thorough in your note-taking from any correspondence with the payer– always get a reference for your call

DYLAN: If you find that you’re spending more time chasing down denials and rejections than you are focusing on your clients growth or on how to make your business grow– you may want to consider employing the help of a medical billing service

MAGGIE: If you would like to learn more about the in-house billing service for SimplePractice users that Dylan and I help run, visit our website at www.simplepractice.com/smartbilling-pro and take our quick questionnaire to see if you’re a good fit

DYLAN: That’s all we have for you today, thanks so much for tuning in. As always

–Keep it Simple!

Negotiating Your Contracted Rate Webinar slides:

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Ask a Biller 9: Rejections and Denials Slides with photo of Barabara Griswold, LMFT.

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