Wait, Don’t Write Off That Claim!
March 2019 Issue
The sentence almost every business owner hates the most is, "We'll have to write it off." It is just as painful and frustrating every time no matter the dollar amount of the claim. What if I told you there were more avenues available before you conceded to a write-off?
Every insurance carrier outlines their appeals process, and sometimes our claims can get all the way through that appeals process with adverse determinations, then comes the dreaded letter saying you have exhausted your appeal rights. While your appeal options for that carrier may be exhausted, the game is not over.
Depending on the denial, you have a few more options to fight the good fight before you take the loss. Here are some lesser known options to try:
One-time exception. A one-time exception is offered by some insurance carriers when a claim is denied for being past its time limit for filing. If you have a claim that is denied for that reason, review the insurance company's filing limit policy and any exceptions they may allow. Most insurance carriers outline exceptions in certain situations in their policy manual with instructions on how to submit that one-time exception.
External review. In most cases, if your claim was denied for lack of medical necessity or the item is considered experimental, you, as the provider, have a right to an independent external review of that claim.
Insurance companies in all states must participate in an external review process that meets the consumer protection standards of the healthcare law. During this process the claim will be reviewed by an independent third-party reviewer. This reviewer will be unbiased and does not receive any financial incentives on the outcome of the process. To learn more, visit www.cms.gov/CCIIO/Resources/Files/external_appeals.html.
Insurance commissioner.If you feel your claim was mishandled, treated unfairly, or denied improperly, providers have a right to file a complaint with the state insurance commissioner. Each state has a website for their insurance department, and the National Association of Insurance Commissioners has a map of the states and jurisdictions. To find the contact information for your state's insurance commissioner, visit www.naic.org/state_web_map.htm.
These are three great options to use before you chalk the claim up for a loss.
While these options are not a guarantee of payment, the extra effort is always worth it. I always recommend to our clients not to accept a loss until they know their team has tried every play and every angle and fought as hard as they could. If it fails, the write-off will still hurt, but at least you know you went down fighting.
Erin Cammarata is president and owner of CBS Medical Billing and Consulting. She can be contacted at firstname.lastname@example.org.