Your top medical billing denial management questions, answered

Medical billing denials can be a source of frustration — and lost revenue. But the truth is that managing payment denials doesn’t have to overwhelm you or your staff. To assist in helping you better understand the denial process, this blog post provides answers to readers' top medical billing denial management questions.

Many payers publish the top reasons for their participating providers — and some are available in the public domain like this list.

After claims submission, the most efficient solution is to completely automate the query process. After a set period of time based on the expected payment cycle for each payer — 14 to 18 days, for example, from Medicare — engage a bot to query the status of the claim. If it’s been referred to medical review, for example, then route it to the work queue of the appropriate staff member to follow up. 

If this automated workflow is not possible, train staff members to make the query online to review claim status. (Arm them with hotlinks to claims status portals like this one and embedded user credentials to boost efficiency.) If there is a problem, then make contact by telephone. If the issue can’t be resolved with a customer service agent at the payer, then make your query via written correspondence.

Unfortunately, insurance companies don’t always have the most accurate information when you request benefit information. A patient may have left a job and that cancellation hasn’t shown up in the payer’s system yet. 

Or there has been some other change that hasn’t been processed. Although there are challenges, it is still always better to conduct an eligibility check and verify what you can. 

I also recommend asking patients when they schedule and when they check in to the practice if there have been any changes to their insurance. It never hurts to complain to the payer if you find this to be a problem, and please do have a process to swiftly contact the patient after receiving a denial despite the verification of benefits.

Another tactic to address these denials is a more strategic one — address the issue in your payer contracts. Add a section that you are reliant on the information presented by their company and their beneficiary at the point of care; if said information is provided incorrectly, it represents the liability of the payer — not you. Engage an attorney to provide contract-appropriate language.

Possibly, but likely not. When you receive a denial returned to you, the Claim Adjustment Reason Code will be accompanied by a two-digit alpha — CO for “contractual obligation” and PR for “patient responsibility.” 

If the denial is reported as a “CO,” the payer is indicating that you have a contractual obligation to accept the non-payment. Only if there is a PR can you transfer the balance to the patient, which may be referred to as “balance billing.” 

Now, you certainly can communicate with the payer and argue your case, but most denials must be handled directly with the payer.

For example, Medicare pays in 14 days and Blue Cross pays in 21 days so should we work these within 3 days after the normal clean payment? 

Following payers’ payment cycles is certainly “best practice.” It is reasonable to follow up 3 to 5 days after you expect the payment to arrive.

I recommend following the procedure for resubmitting a corrected claim as outlined by the payer; this is often referred to as the “reconsideration” process.

We have many requests for medical records from one insurance company. They request medical records on almost all claims. Is this legal? It seems like a delaying tactic and am considering going to the board of commissioners. 

Based on your question, I assume that this payer is requesting medical records before payment. (If they are requesting them after payment, that is another issue). 

If you feel that this payer is stalling, I would contact your designated provider representative and state your concerns verbally. Then, I would send a letter. 

I would then ask your physician to contact the payer’s medical director and, again, report it verbally and in writing. Either on this letter to the medical director, or in a separate letter, I would carbon copy the state insurance commissioner. If you want to up the ante, another stakeholder to carbon copy is the attorney for the payer. (The lead counsel is typically on the payer’s website.)

Many states offer a portal to submit complaints, and another partner in your fight is your local and state medical society. Contact their advocacy division. 

Of course, it pays to reflect on the issue before you pull in the troops. If, for example, the payer is asking for medical records on an experimental procedure or they have announced that records are required, then they may have a valid reason for their request. 

There are many best practices for collecting patient payments. Here are a few suggestions. 

First, it’s important to have a patient policy in place that states that patients pay co-pays and other patient responsibilities at the time of service. It can be at check-in or check-out depending on the situation. It should also lay out self-pay requirements. Preferably all self-pay amounts should be at the time of service. 

Barring that, you might consider offering discounts for self-pay patients who pay within a period of time such as 30 days or charging late fees for those who don’t. 

Be sure to comply with all elements of the No Surprises Act. You can also let patients know about balances due when they schedule an appointment. While there are other strategies, these are a good starting point.