Simple Steps to Appeal a Medical Necessity Denial

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There are many reasons for insurance carriers to deny an insurance claim. The reasons for a denial of benefits and in the difficulty of resolution of the denial may vary among payers but the first thing that is necessary before any further action is taken is to know WHY the claim was denied.

One of the most common reasons for insurance denials is incorrect information. Transposition of letters or numbers is an easy and a very human mistake.

Still, it can cause a great deal of frustration and delay for both the office and the patient which is why attention to detail is of the utmost importance for your coding, billing, and medical records team.

Submitting the right claim for the wrong patient and vice versa is unfortunate but rather common as well. The busier the practice, the more opportunity there is for mistakes, but again, a thorough and detail oriented team or a system of checks and balances will go a long way in resolving these sorts of mistakes.

Your medical office can avoid denials for simple mistakes by asking these questions: Is the patient’s personal information correct? Are the identification numbers, group numbers, policy numbers, and any other identifiers correct and complete? Is the physician’s provider identification number correct? Making certain of these items can save a great deal of time and aggravation later.

Another common mistake is incomplete coding, procedure, diagnosis, or treatment information or the incorrect use of modifiers. Be sure to use the most up-to-date codes available. Furthermore, and possibly the easiest mistake to avoid is confirmation of benefits. Before any procedure, treatment, or visit is scheduled the patient’s insurance benefits should be verified.

Is the patient still insured by the company of record? What are the benefits? Is precertification or prior authorization required? What are the time references for diagnosis and treatment? Is there a preexisting clause and what is excluded under it? Further, have you billed the patient’s primary payer first? Is there a secondary insurance? Is this an injury that is the result of an automobile or work-related accident and as such a part of litigation proceedings?

These are easy questions to ask and relatively easy to answer. While it may take some time on hold, the time spent waiting on hold or calling different carriers and departments is still far less costly than a denial of charges and being faced with submitting an appeal.

Another more unpleasant possibility is that a claim will be denied as “fails to meet medical necessity”. In this case, just like the former examples, the specifics of the denial are of the utmost importance. When you are certain of the specific reasons for denial there are five simple steps you can take to appeal a medical necessity denial.

  1. First, make certain all information is correct and clear.
  2. Obtain specific plan information as it relates to this diagnosis, treatment plan, or procedure.
  1. Familiarize yourself with the appeal process for the specific insurance or payer you are submitting the appeal to.
  2. Verify the updated medical necessity guidelines according to the payer’s policy.
  3. Be prepared to prove, through documentation, the reason(s) that this procedure should be considered medically necessary through case studies, scientific evidence, and common practice for your specialty and locale.

While a denial is frustrating for the physician, the clinic, the staff, or the facility, remember that it is especially frustrating for the patient. Keeping in contact with the patient regarding the progress of the claim is very helpful in soothing jangled nerves and keeping dissatisfaction at bay.

A level head prevails in all matters related to insurance carriers and their policies. Knowing the claim specifics, following up in a timely and consistent manner shows the payer that you are dedicated to the positive resolution of the claim for your office and your patient. The word to the wise is “documentation”. Always document whom you spoke with, the date, the time, their title, and the outcome of the conversation.

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