Healthcare revenue cycle management companies must grapple with a lot of different situations and processes on a daily basis. Prior authorization, claim submissions, both of these are two examples of common things that must be addressed. Another situation that may arise is the denial of insurance. There are different ways of addressing these denials that may help streamline the process.
When an insurance denial arises, there is the option to file an informal or a formal appeal. In the case of the former, this is a relatively simple process where the insurer that made the denial is contacted via phone. If necessary, these informal appeals should be escalated to a supervisor. With formal appeals, the process is significantly more intricate. However, all managed care organizations must have a formal appeal process in place by law.
If a patient has a self-insured plan, providers may wish to contact the patient’s employer’s human resources department for additional information during the appeal. If it’s a Medicaid managed care patient, contacting Medicaid customer service or a state ombudsman can result in further information regarding the denial. For patients with commercial plans, information regarding the appeals process is available via the provider’s policy or contract with the insurer.
This update is by Medical Accounts Systems, a full-service healthcare revenue cycle management company providing a number of services including insurance follow up and managed care disputes, physician reimbursement, extended business office services, and more. For additional information on our services or for any questions you may have on topics such as hospital bad debt, please call 877-759-6315.