Your main goal is simple: you get your practice paid. But your goal isn’t a simple undertaking, especially when it comes to appealing denied claims. It’s a messy, convoluted web of tasks made up of multistep to-do items. But that doesn't mean your claims are unrecoverable, right?
Approximately 49.7% of denied claims are caused by front-end problems, per the Change Healthcare 2020 Denials Index. Change Healthcare found these front-end issues as the largest ones:
Though most denials come from front-end problems, Change Healthcare found these additional reasons that denials occur:
The aforementioned list isn’t an exhaustive list; however, it shows a variety of denial causes you probably have in your denied claims list right now. Some of these issues are unrecoverable, yet avoidable. To learn more information about how to avoid denials, read our past article.
Fortunately, many denials are recoverable, but the process tends to be a lot of work. Below, we’ll dive into the appeals process and how Rivet’s denials management tools will change the way you work appeals.
The 4 basic steps of the appeals process1. Establish appeal legitimacy.
We’ve talked about possible denial reasons, but it’s likely your practice doesn’t have the resources or time to file every appeal. Furthermore, some denials are hard denials, meaning the claim cannot be recovered and you will not receive any payment from the insurance company. You’ll need to make sure a denial is worth your time and effort before jumping in.
Rivet’s Denials Management software helps you organize your claims data in an easy-to-use format. You’ll see line item claim details, adjustment codes and diagnosis codes all in one place so you can easily solve problems.
Once you’ve decided to appeal a denied claim, you’ll need to gather anything that could be useful in obtaining payment, such as the following:
With Denials Management workflow tools, you can automate forms and data fields in Rivet so you can reduce error and manual data entry. Keep continuous record of instructions, payer policies and payer contact info by payer and denial type.
You’ll most likely get the mailing and any electronic sending addresses from the company’s website when you get your insurance-specific forms. You may see it on the EOB, but be sure that is actually the correct address for sending appeals. You don’t want to do all the necessary paperwork to have nothing come of it.
Save useful information in Rivet for easy reference when working an appeal with the same payer.
Now that you’ve received an answer to your appeal, you can do one of two things:(1) Do a happy dance because you got paid what you deserved!
(2) Take your appeal to the next level because you didn’t get paid what you deserve.
The following are the three different levels of appeal:
If further action is needed, you may report the insurance company to your state medical association. They will help you file a formal complaint and possibly launch an investigation into the insurance provider’s claims processing.
If you’ve worked in denials management before, you know that filing deadlines need to be tracked so that you stay on top of denied claims before you run out of time.
With Rivet, you can automate your team member’s task lists, track all of your denials to completion and stay on top of deadlines.
Want to know more about our Denials Management or other products? Download our info page on our denials management software or schedule a demo.