Five Simple Ways to Avoid Commercial Health Insurance Claim Denials

Hospitals and clinics tend to operate on thin financial margins. They rely on commercial health insurance companies to pay their bills on time in order to keep the lights on and the employees paid. Claim denials can mess up this system. The average claim denial can be avoided – as long as your billing department employees follow the five steps outlined here. Of course, if those claim denials end up going through the state appeals process, they can still be collected on, but let’s focus on avoiding those denials in the first place. Here’s what you need to know.

Five Ways to Decrease Your Overall Claim Denials

As you already know, claim denials create quite a few problems. In fact, they are the main reason why many hospitals and clinics end up going bankrupt. Those claim denials pile up and make the financial situation untenable. Thankfully, you can decrease those denials by using this system.

1) Stop Holding on to Your Denials.

The longer that you sit on these claim denials, the worse your financial system will get. You need to take charge right away and deal with them. You don’t want them to end up in your bad debt bucket or on the wrong side of your balance sheet. Plus, the longer you hold onto them, the more likely they are to get forgotten.

2) Do Some Research

The main question to ask here is “why was the claim denied?” Your employees will have to ask the commercial insurance company in order to receive clarification.

3) Track Those Claims

Never forget about your claims. Place one or two employees in charge of tracking them to ensure that the follow-through process occurs.

4) Look For Patterns

There many some evident patterns behind the claims, such as misspelled names, miscoded therapies, or even the wrong birthdate. Find out what the patterns are and fix them.

5) Reduce Your Claim Denials Overall

Follow all of these steps and you’ll find that your claim denials will go down. It’s all about jumping on them right away and determining what the issue is. If they end up going through all of the appeals, then stay on top of them.

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Claim Denials Can Be Avoided

The best thing to do is to avoid these claim denials. Many are sent back by the commercial health insurance company because the amounts are wrong, they are miscoded, or proper approvals weren’t requested and received. When the health insurance company sends back an unpaid claim, they’ll explain why. Your billing employees will need to check on this reason and find a way to correct it before resubmitting the claim.

At this point, the clinic has their billing employees send in an appeal to the health insurance company. According to current laws, there are three of these appeals available at the state level.  The insurance company then goes over the newly appealed claim denials and comes up with a new judgment. In some cases, the claim is paid. This makes everyone involved happy. The hospital no longer has to worry about that unpaid claim and they under with more money in their bank account.  In other cases, the insurance company might just pay a portion of the claim. This is called an underpaid claim. The reasons for these depend on the allowed amounts and any preapprovals – basically the same as the ones from the first round of claim denials.

On top of this, the insurance company could also keep refusing the claim outright. As we already stated, the hospital or clinic can go through three rounds of these appeals, even if the claim is underpaid. The collections process allows for this. Every time that the claim is sent back for an appeal, the odds that it will get paid go down. In some cases, the claim is partially paid and then partially paid again, leaving a balance by the end of the appeals process. Each time this happens, it costs the hospital more money and creates additional work for the billing employees.

Stop Your Claim Denials From Piling Up

After the three state-level appeals process is completed and the claim denials are still in place, your hospital or clinic has a choice. That money usually ends up going uncollected. It goes to your accountant’s office  where it ends up in what we call a “debt bucket.” This is a list of permanent debts on a balance sheet. The medical facility needs to make even more money to make up for this growing list of debts. Since hospitals and clinics have bills to pay so that they can stay open, this list of debts can be extremely problematic. The reason why most hospitals go bankrupt and close their doors is due to them.

Thankfully, there is a solution to getting those claim denials paid. This involves the Federal ERISA process. While many hospital administrators have heard of it, they aren’t sure about how to even begin using it.

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Use Federal ERISA Laws to Collect On Them

A Federal ERISA appeal can be filed on all of those unpaid or underpaid claim denials. The problem with this is that many of these hospital administrators aren’t sure of the process. As you can imagine, this federal process is quite complex, meaning that many billing departments don’t know how to work through it. They aren’t taught this in schools. Plus, many of the employees in those billing departments are busy either with sending out current bills or wading through state-level appeals. They just don’t have to time to figure out Federal ERISA appeals. This means that in most cases, those claim denials are written off and add to an already growing pile of debt.

What is ERISA? It stands for the Employee Retirement Income Security Act. It was enacted back in the 1970s and was initially designed to protect employee retirement plans. Over time, it’s become a federal law that protects self-funded healthcare plans as well.

Essentially, the Federal ERISA appeals process is designed to get your hospital the money that it’s owed from those commercial insurance companies. Using it requires the use of a specialized billing process. It all starts with your accounting personnel. Rather than having them place your money in a debt bucket, call in a specialist. Take those claims and place them in a file.  Then call in an expert, such as ERISA Recovery. We’ll need a few things from you, including that list of claim denials and some other information. We can take it from there and will file those Federal ERISA claims for you. On top of this, we have a guarantee in place stating that we’ll recover at least one million dollars in denied claims for you within 12 months. We also don’t charge anything up front.

Seek Help From An Expert In The Field

Is your hospital or clinic burdened with commercial health insurance claim denials? You don’t want your hospital to end up going bankrupt or shutting down – not when there’s money out there that you can still collect. This is why you need to contact ERISA Recovery today. You can reach us at (972) 331-4140 or by filling out the contact form on our website. It’s time for you to move forward and take control of your hospital’s financial future!