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How to Appeal Denied Claims

Julie McCoy, for HealthLeaders Media, January 10, 2011

To make the call, look at the claim for clues. Is this a high-dollar claim? The more money that is at stake, the harder and longer you should fight for payment, Cronin says. Is it a type of claim that you submit often? If so, it may be worthwhile to establish that the claim is valid so the insurer doesn’t continue denying them later. 

But if it is a claim for a relatively small amount of money, or a one-off procedure, the answer may be different.

“Sometimes those have to be put aside and you chalk it up to how the system works,” Cronin says. “You lost that one but you’ll win others.”

Avoid denials by reading the contract carefully

Many denials can be avoided by knowing the payer’s payment policies well, says Eileen Parsons, JD, an attorney with Ver Ploeg & Lumpkin in Miami. You should study the payer’s policies before signing the contract, particularly if your practice provides a certain type of treatment or procedure that is new or different or otherwise might be denied, Parsons says.

“This is particularly important when this care makes up a large part of your practice and your revenue stream,” she says. “You don’t want to get into this contract and then realize down the road that they are going to deny all of those claims. At that point you could be forced to appeal claims all the time, when it could have been avoided with a careful reading of the contract.”

Contracts also should be scrutinized for language that restricts your ability to renegotiate or void the contract if the payer substantially changes payment policies, Parsons says. If the payer changes the way it reimburses you for a type of care that is key to your business, you need the ability to renegotiate or terminate your contract. “At least understand up front what the requirements are going to be for the claims that matter most to you,” she says.

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