Working Common Denials (part 1)

Donna White

Donna White

By Donna White, Principal Consultant and Owner of Legacy Consulting Services and Legacy Billing Solutions in Montgomery, Alabama.

Depending on your practice, there may be several types of top denials. In today’s article, we are going to review best practices for follow up on some of the most common denials, regardless of specialty.

Coverage Termed/Expired

Per the EOB, the patient’s service denied as Coverage Termed or Expired at the time of the service. In your practice management system, check the Insurance Screen’s eligibility area to see what eligibility information was obtained during eligibility check. Is there an effective date for the Insurance Plan? If not, use the provider’s web portal, or call the eligibility line for the payor to re-check the patient’s eligibility.

If the patient was eligible at time of service, speak to an insurance representative, let them know the effective date and ask that they have the claim reprocessed.

If the patient was indeed not eligible at the time of service, try calling the patient to see if they have a new insurance that can be billed. If they do, get all of the insurance information including Insurance Name, Billing address, Subscriber ID, Subscriber Date Of Birth, Group Number, Phone number from the back of the card and Payor ID if possible. Enter the information into the patient demographics of your PM system and re-submit the claim accordingly.

If you get the patient’s voice mail, leave a brief message that you need to speak to the patient about their account with . Do not leave too many details to prevent HIPPA violations. If the patient does not call you back, call and leave one more message, then send a letter letting them know we are trying to reach them about their insurance information for (list out the date(s) of service) and if they do not respond back within 15 business days of the receipt of that letter, th
e full balance will be dropped to patient responsibility.

Incorrect Patient Identifier
Per the EOB, the patient’s service denied for Incorrect Patient Identifier (wrong Insurance ID, name incorrect). Check the patient’s chart to see if their driver’s license and insurance card are scanned into the system. Compare the name on the scanned ID cards to what has been input in the system or compare the Insurance ID in the system to what is on the scanned ID card.

If they match, call the payor and speak with a representative to have the claim reprocessed. If they do not match, update the practice management system to the correct information and re-bill the claim.

If no ID cards are scanned into the system, send a task to the front to follow up with insurance information. If the office does not have any information different than what is in the system, call the patient to confirm the spelling of their name or have them read their Insurance ID number to you. If you must leave a message, leave a general message stating you need to talk to them regarding their account. Do not provide any additional specifics to prevent HIPPA violations.

If no response from the patient after a 2nd message, send a letter to the patient letting them know their insurance is not processing their claims due to an issue with their member ID number or name and that you have tried reaching them with no response. If no response, drop the balance to the patient so they will receive a statement during the next statement run.

Today we have reviewed common front office denials. We will review best practices for other common denial types, like Missing Information and Maximum Benefits in future blogs.

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