Fight for Insurance Carrier Payment 

Fight for Insurance Carrier Payment 

Before denials and resubmissions take a toll on your practice, have a game plan that gets you paid.

Fighting with an insurance company to get claims paid can be difficult. Accounts receivable staff must be on top of their game because incoming payments are needed to pay the light bill, the doctor’s malpractice premium, our salaries, and other necessary practice expenses.

Build a Winning Team 

To champion your cause, you must have the right people in the right place to handle the claim. This team must understand the denial and know the best way to resubmit the claim. Beyond their skills and knowledge, they also must have:

  • Resourcefulness – To get help from others when needed
  • Persistence – To be a problem solver
  • Tenacity – To finish with a resolution
  • Ownership attitude – To care as if these payments belonged to them
  • MVPs (most valuable players) will:
  • Ask the claims examiner the right questions;
  • Review the entire billing record, not just the one denied charge; and
  • Know and understand payer rules.

Face Your Opponent

To begin a successful fight, you must first understand the denial. The five most common denials involve: bundling, non-coverage, insufficient information, failure to prove medical necessity, and eligibility of the patient.


When you report a code combination that may not be billed together, that’s bundling. To avoid this type of error, check National Correct Coding Initiative (NCCI) edits before submitting claims.
In the event you receive a denial based on unbundling, check the NCCI tables:

  • If they show your combination of codes can never be billed together, the denial was correct.
  • If they show your combination of codes may be billed with an appropriate modifier, determine if a modifier would be appropriate and, if so, which one. Resubmit the claim as a “corrected claim.”
  • If they show your combination of codes does not have a bundling issue, send an appeal asking for reconsideration, with a copy of the documentation.

Non-covered Denials

“Non-covered” can mean a lot of things: The service may not be a covered benefit for the particular patient; the service may be covered, but not the CPT® code billed; or the diagnosis code may not support either the service or the coding.
If the payer doesn’t cover the diagnosis code, review the patient’s chart. If another diagnosis was documented, you can bill a corrected claim.
Example: Depo-Provera® 150 mg (J1055 Injection, medroxyprogesterone acetate for contraceptive use, 150 mg) is administered with an original diagnosis of Z30.13 Encounter for initial prescription of injectable contraceptives. After re-examining the chart, it is found that the patient received the Depo-Provera® for N80.0 Endometriosis of uterus. Submit a corrected claim, with the appropriate diagnosis code tied to the procedure code.
Remember: Never make any changes to the documentation after the original claim is filed.
If the payer doesn’t cover the CPT® code, review the patient’s documentation. If the wrong code was selected, you can bill a corrected claim.
Example: A patient has a wellness visit, which was documented, along with instructions to change her blood pressure medication. Code 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. … Typically, 10 minutes are spent face-to-face with the patient and/or family was erroneously selected and billed with ICD-10-CM Z00.01 Encounter for general adult medical examination with abnormal findings. Change the CPT® to the age-appropriate wellness visit code, and submit a corrected claim.
If the service is truly a non-covered service under the patient’s policy, the service should be billed to the patient. It may be helpful to have a signed Advanced Beneficiary Notice of Non-coverage (ABN) form on file for the patient. Unfortunately, not all carriers use or recognize an ABN.

Claim Needs More Information

Most injury-related claims are denied until the payer can determine the cause of injury. Payers send out communication to the provider, as well as to the patient, asking for details about the injury. Was the injury related to the patient’s employment or to a motor vehicle accident? Is there another agency that should be responsible for this claim?
The details of the accident can be provided through accurate diagnosis coding. By selecting a diagnosis from Chapter 20, External Causes of Morbidity (V00 – Y99) on the original claim, in addition to a diagnosis from the Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes (S00 – T88), most denials of this nature can be avoided.
Other types of claims that “need more info” may be for college-aged dependents. The payer will want proof that the dependent has remained a full-time student. In this case, the patient’s parents need to obtain this information, such as a statement from the college’s registrar.
Using unlisted codes also requires more information. These codes are used when there is not an adequate CPT® code to describe the services rendered. Usually, the operative note documentation will suffice, as long as the payer can identify what part of the surgical note applies to the unlisted code.

Claim Lacks Medical Necessity

If the service is purely cosmetic, the patient is responsible for payment. The claim should not be adjusted based on the payer’s denial due to lack of medical necessity.
If the service was medically necessary, the problem could be the frequency in which the service was billed. For example, patients who have diabetes mellitus will customarily have an HgA1C checked every 90 days. Billing the test in shorter intervals than 90 days will cause a medical necessity denial. If the physician has a medical reason to check the levels more often than 90 days, an appeal may be submitted, with the chart documentation.

Patient Eligibility

Claims denied due to patient eligibility are the patient’s responsibility, and are out of bounds until sufficient and correct insurance information is obtained.

The Winning Way to Overturn Denials

Knowing the best way to overturn a denial is instrumental in expediting payment. A claim should not be resubmitted simply to try and force a different outcome. Billing claims multiple times never gets results.
A corrected claim is always appropriate when diagnosis codes or CPT® codes need to be changed or modifiers need to be added. Be sure to identify the claim as “corrected;” failing to do so may result in another denial because the payer may see this second claim attempt as a duplicate.
Beat the buzzer: Allowing several months to pass before you correct the claim issue could result in a timely-filing denial.

Step Up Your Appeals Process Game

An appeal is appropriate if you’re dissatisfied with the initial determination on a claim. Filing an appeal should include all pertinent medical documentation. The different levels of appeals vary from payer to payer. Medicare’s level of appeals includes:

  • Redetermination must be done within 120 days from the date of the initial determination.
  • Reconsideration by a qualified independent contractor is a review, which must be done within 180 days from the date of the Medicare redetermination notice.
  • A hearing by the administrative law judge (ALJ) has to be performed within 60 days from the receipt of the reconsideration notice, and there has to be at least $150 in controversy.
  • Review by the Medicare Appeals Council (MAC) of the Departmental Appeals Board should be conducted within 60 days from the date of the ALJ decision receipt.
  • Judicial review in U.S. District Court has to be requested within 60 days from the MAC decision and at least $1,460 remains in controversy.

Check with other carriers for their appeal levels. Also, get your providers engaged in the appeal process. They need to know when a portion of their claims are being denied. The provider may be able to equip you with an appeal letter explaining in detail what was performed, and why.
If all else fails, pick up the phone and call the payer. Hearing the problem over the phone may turn up new information. For example, a claim for 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity … Typically, 25 minutes are spent at the bedside and on the patient’s hospital floor or unit was denied as “bundled in with a previously paid service;” but there is no other service on this patient’s account to which bundling of the 99232 could occur. After contacting the payer, it is found to be a provider/group linkage issue. Sometimes telephone conversations are needed to work through these details.

Wendy Grant-Denton, CPC, has been in the medical industry since 1977. She works as a revenue cycle manager and coding analyst for Community Health Systems. Grant-Denton is a member of the Little Rock, Ark., local chapter. She also served on the AAPC Chapter Association board of directors from 2009-2013.

Certified Professional Coder-Payer CPC-P

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