Insurance Claim Denials and Appeals

Claim or coverage denials are best avoided by being as proactive as possible. Understanding the plans and obtaining pre-authorization is likely to reduce unwanted and unexpected denials.

However, claim denials do occur and the American Medical Association has reported that a significant proportion of physical revenue can be associated with underpaid or denied claims.

Moreover, the majority of claim denials or underpayment can arise from errors attributable to care providers and payers. Therefore, it is important that physicians and staff learn to analyze rejected claims, manage claim denials effectively, and implement appeal strategies.

Tips for improving claims management overall:

  • Understand the claims appeal process applicable to your local, regional and national payers.
  • Review claims before submission. Use a reference sheet to cross-check for common coding errors and proper payer procedures.
  • Regularly evaluate payers' explanation of benefits (EOB) for potential errors or underpayments.
  • Record claim follow-up including a summary of payer information, source(s) and reasons for denial, as well as any actions taken.
  • Using standardized professional claims appeal letters may facilitate the process, and payers may be more likely to respond quickly. Clearly state the rationale for the appeal, date of service, patient information, and appropriate documentation for all patient care provided.
  • For payers unfamiliar with T.R.U.E. TEST®, it may be helpful to note that it is the only allergen patch test approved for marketing and sale in the United States

Disclaimer: The brief information included here about coding and reimbursement is for educational purposes only. It should not replace current Medicare or specific payer policies, state or federal regulations, medico-legal practice guidelines, or consultation with coding experts or attorneys. Users should always consult payers for final guidance and about changes in coding and reimbursement practices. SmartPractice® and SmartPractice Denmark® assume no liability from the use of this manual.

For more details on patch test reimbursement, contact our customer service department at 1-800-878-3837.