Coach Jennifer: This person has a job in billing and they’re a little bit nervous because those denials that means money coming in, so that’s a little bit nerve wracking, making sure you get that money. So when it comes in, what are the steps to fixing that claim? How do we get that claim?

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The denials come… It could be a simple thing. It could complex. It’s going to depend on the denial. It could say one line item is denied, it’s inclusive and you look at it, well, it’s missing the modifier. Oops, somebody missed a modifier.

They could just be requesting other health information or a primary EOB, an accidental detail form. Those could be classified as denials even though they’re not processing the claim yet because they’re requesting other information. So, denial is kind of a loose term that we use. Anything that’s not paid is pretty much denied but there’s suspended claims, there’s pending claims. They’re not all denied. Or you could have that ever important medical necessity or even that missing authorization.

It depends on the reason for the denial. A claim that’s denied, missing that modifier, that’s a corrective claim – a correction, not an appeal. Some people might call it a reconsideration. It depends on the insurance company.

This is an example of United Healthcare. I just cut and paste the top and the bottom of their paper claim form. So if you’re going to send a claim in via paper to United Healthcare, they have a form that’s required and a lot of the insurance carriers actually have a form that they want you to send along with it. Because what happens if you don’t send this form? You’re sending a paper claim. Well, they’re going to get it. They’re going to process it but you’ve already send in that claim, so they’re going to deny. It’s a duplicate. So this form is drawing their attention to, “Hey, something’s been changed.” So, in this form they say, “Make sure you put the claim number on there. Make sure you include this information.” And then they have little check boxes to send in. Say, “Oh, I corrected the claim. Something else needs to be done here.” “You denied this exceeding timely filing. Here’s my proof that we didn’t exceed the timely filing.” Say, they have a second insurance company and we sent it there first or you’ve got the other EOB paid.

They also allow online corrections with United Healthcare. So you could just sit for a certain reason, some are simple ones, “Just please reprocess this claim for this reason. I adjusted the diagnosis. I added a modifier.” Things like that. “Just send it online.” Actually, something small like that are local medical assistants. They’ve told me, “You can send the claim a hundred times a day if you want.” They’ll keep reprocessing it. So, when we get it there the right way, then it’s going to process and pay, that they will just keep reprocessing claim. They don’t deny it as a duplicate. So, it just depends on the carrier whether you could possibly just resubmit the claim with the new information electronically. They might process it. Medicare is one of those. It depends on the denial code that they gave.

A claim that’s been pended or suspended – We call it denied but they’re actually waiting for more information, so it’s pending further information. Medicare sometimes calls this suspended claim. They’re waiting for additional information. They’ll process it but they need to get that information first before they’re going to process it. So, typically for coordination of benefits, they may say the patient has another health insurance plan and you need to go through them first. They may have conflicting information or they need additional information. We encounter this all the time in Orthopedics, people falling, injure themselves. So, they want to make sure that it’s not in relation to possibly a Worker’s Comp, a liability, automobile…, somebody else who could maybe pay that claim before they’re going to pay it. So, they’re pending accident detail information.

Those are things that the carrier is saying, “That patient’s responsible for this bill for you until we get that information.” So, if we don’t get information, the patient owes you that money because they’re not fulfilling their obligation with the insurance carrier. So, you would then put the claim to the patient responsibility, make phone calls to the patient. They’re getting their statements.