You finally got credentialed, you are now up and running, submitting your claims and then it happens...days turn into weeks, weeks turn into months, and it's crickets!
What happened? Why have I not received payment yet?
And then you get the notice...in the mail...and it says...
You try to call the claims department...you get nowhere! You try to talk to your client...you get nowhere! What's a clinician to do!
I got you covered! I've been there. I used to work for 3 major insurance companies so I have some background in the insurance field and want to provide some insight to help you...
CONQUER CLAIMS SUBMISSIONS!
Here are 7 reasons why you may receive a claim denial along with tips on how to resolve them.
1. Wrong Client Information-
Believe it or not, this may be one of the most common reasons claims are denied. Claims systems are very particular. If you misspelled a name, entered a name that is not on the insurance card (ex. maiden name), or if you have the wrong address entered, it could result in claim not being accepted and denied.
Prevention: Verify all client and policy holder information by reviewing the clearinghouse or provider portal used to enter the claim. If you are using a system that is part of your EHR, I suggest that you always use the insurance claims website to verify their information. Also make sure that the information in the insurance system is the same that they provided you on their intake or demographic form. In many cases, clients may move and update their address on your form, but have not contacted the insurance company to update the information. The client must call their insurance company to change their information. A way to help cover you is to have an payment agreement form and insurance release form which outlines what is client's responsibility should insurance fail to pay in a timely manner.
2. Service Not Covered- This can include an exclusionary diagnostic code, procedural code, or discontinued diagnostic code. I discovered that there was a period of time that an insurance company was no longer covering a specific diagnostic code (F411-Generalized Anxiety Disorder). Mind you that I had been using that code for quite some time with this particular client, so imagine my surprise when I checked and noticed that some of my claims were denied! After much research, printing ERA's, contacting claims, and scratching my head, I finally learned the source of the problem...during a 6 month period, the insurance company had decided to not cover F41.1 for any procedural code (90837 or 90834)! Luckily, this client had a dual diagnosis so I was able to resubmit with the other diagnostic code.
Prevention- Pay attention to your policy/contract as they will give you information on what diagnostic codes are covered for which procedural code (i.e., exclusionary codes). In addition, some major insurance companies provides monthly newsletters. In these newsletters, they provide vital information concerning changes. So they did notify me, I just had not paid attention to the changes. Thankfully, the changes were not permanent and they realized their faux pas in disallowing the diagnostic code for GAD.
3. License Level- Some licenses are unable to submit for certain types of services. For example,
in Texas, there has been a battle regarding allowing LMFT's to "diagnose" and even get "reimbursed" by insurance companies. It finally got resolved by the Supreme Court in 2017 (see article here), however, it varies by state. Another example is that LPC's are unable to be credentialed with Medicare (as of this writing). As such, if one of your clients has Medicare insurance, and the rendering provider is a LPC, then the claim will be denied. This is especially important for group practices that may have clinicians with varying licenses.
Prevention- Again, review your contract! Make sure that your license is allowed to submit claims. Please note that all insurance companies will state the following: "Benefits and eligibility verification is NOT a guarantee of payment." So just because the client has the benefits, it does NOT guarantee that you will receive payment.
4. Untimely Filing- Always check your contract for this information. Most insurance companies have a certain timeframe within which to submit claims. Now this varies depending on the insurance and it could be from 45 days up to 365 days. Even EAP insurance plans have date limits. It is wise to always check and read your contract and even refer back to your contract as the insurance company will not necessarily provide this information to you.
Prevention- I highly recommend that in order to prevent this from occurring is to submit your claims daily! Set aside some time each day at the end of your day to submit all your claims. Not only will this prevent untimely filing, but it will also speed up the time in which you get reimbursed. In my experience, the longest it takes to receive payment from MCO's (Managed Care Organizations) is 7 calendar days. If it takes longer, it is due to either it being reviewed for possible denial or because multiple services for one client was submitted (leading to longer review of the claim).
5. Wrong Payor- This involves submitting the claim to the wrong insurance company. This may also occur is due to client's insurance plan altogether. Sometimes, the client's major medical insurance plan may not be the same for their mental health coverage. As such, the insurance company listed on their card may have "carved out" the services for mental health to another insurance company. Confusing, I know. That's why I have my Conquering Insurance Claims Workshop where you can register and receive more detailed information about this dilemma and how to remedy it.
Prevention- Another prevention is to make sure you know what type of plan the client has. You can also look at the front and back of the card for information on how to verify eligibility and benefits. The client may not be aware that they have "carve out" insurance.
6. Dual Coverage- : This is as its name implies...a client has more than one insurance coverage/company. A client may carry secondary coverage. Basically, this means that the client or insured has another insurance plan. Another way that this can take place is when clients are changing or have changed insurance plans and the new insurance company believes that they are still covered by their old insurance. An example of this is having a college student, who aged out of their parents policy, and has signed up for college insurance prior to the expiration of their previous insurance. Another example can occur if someone has Medicare and Tricare. If your client has more than one insurance, and let's say Medicare is their primary insurance, and due to your license you are not credentialed with Medicare, you will have to receive a denial from Medicare first before you can submit to the secondary insurance.
Prevention- The only way to prevent this is to simply ask the client if they have another insurance plan. In addition, ask the client if there has been any recent changes to their insurance plan (i.e., did they just sign up for the current insurance). If so, ask the client for their previous insurance information as well. Note: if you are using your EHR to submit your claims, you will not necessarily know this information. I highly recommend always checking benefits via the insurance's portal, clearinghouse, etc. They usually have information concerning secondary insurance available to view. For more specifics on how to do this, attend my upcoming workshop, Conquering Claims Submission.
7. Coverage Terminated- Yes it happens. Clients may lose their jobs, or if they are on the open market plan, state funded or federally funded plans (i.e., Medicaid and Medicare),
they may have failed to pay or failed to meet qualifications to remain on the plan. There are times when even the client is unaware of this.
Prevention- Always check eligibility the day of the clients appointment. I highly recommend this practice. Again, if you are using your EHR to submit claims, they do not verify eligibility and benefits for you. It is up to the clinician to verify that the client is eligible. Hence having a payment agreement form that outlines the clients responsibility should insurance fail to pay for the service rendered.
And there you have it! 7 explanations for claims denial and ways to prevent it!
If you are new to claims submission, having difficulty with submitting claims, or you are an out of network provider and would like to learn how to submit claims for your clients, then join us for our next workshop, Conquering Claims Submissions! Receive 3 CEUs for attending. You can attend live or via teleconference, the choice is up to you! For more information and to register, Select This Link!