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By employing a hands-on approach to health insurance claims, patients and physicians can help reduce the number of denied claims and increase revenue.

Claims management often consumes a significant amount of time for physicians and healthcare organizations. Group Purchasing Organization Premier ran a survey and found that Medicare Advantage, Medicaid, Commercial, and Managed Medicaid experienced denials on nearly 15% of all claims. What’s more, 45% to 60% of the denied claims were overturned. According to Gretchen Heinen, RN, PHN, BSN, founder and CEO of Revenue Cycle Management (RCM) solutions company Authsnap, Inc., many physicians are forced to confront revenue issues due to denied claims, and several US hospitals have ultimately had to close as a result of claims denials. However, Heinen urges physicians to remember that most denials can be overturned with a well-constructed appeal letter.

Heinen notes several potential causes for denied claims. For instance, an insurance policy’s umbrella may not cover specific services or treatments, perhaps because they are considered experimental or subject to certain policy limitations. Another possible cause could be incomplete or inaccurate information on the submitted claim. Additional potential causes suggested by Heinen include submitting claims that don’t meet medical necessity criteria, enlisting out-of-network physicians for medical care, not adhering to prior authorization requirements, patients with multiple insurance policies not ensuring that they’ve coordinated benefits issues and untimely submitted claims.

According to Heinen, physicians and patients should familiarize themselves with the insurance company’s explanation of why they denied a claim. Often, patients can use this information to support their case in an appeal. However, Heinen notes that having someone with clinical expertise deal with the appeal would be extremely helpful, as insurance companies typically do not provide fleshed-out responses in their claim-denial letters.

Heinen recommends considering a few points for those who would like to appeal to ensure the most successful appeal process. First, she suggests that physicians and patients avoid solely depending on proprietary criteria. Rather, physicians should employ clinical practice and societal guidelines. Second, Heinen urges physicians, patients, and their teams to thoroughly comprehend the appeal process, as summarized in the commercial payer’s contract. They should speak their minds if they deem anything written in the contract to be unjust. Heinen notes that every payer’s criteria are available for public view. However, this information is sometimes written in tiny fonts on websites. Therefore, all involved parties must read them carefully and pay attention to detail. Lastly, Heinen suggests that whoever is dealing with the appeal has an in-depth understanding of the ins and outs of prior authorization, making sure to educate themselves on any new policies.

Heinen notes that physicians would be best served by arming themselves with a reliable RCM strategy and tracking plan. Maintaining a healthy revenue stream is dependent upon having a low overturn rate, and hiring an expert would be wise if it helps to achieve this goal.