Hospitals have three operational processes in revenue cycle management to respond to insurance claim denials, said Lyman Sornberger, vice president of client development at Charles J. Hilton and Associates law firm.
These processes include informal and formal appeals.
"An informal appeal is simply a call to the insurer that issued the denial. Ensure that you escalate the challenge to a supervisor," Mr. Sornberger told Becker's Hospital Review. "A formal appeal is much more complex, but know that every managed care organization is required by law to have an appeal process."
He said if the claim denial is for a patient with a self-insured plan, providers should contact the patient's employer's human resources department for more information during an appeal. The state ombudsman or Medicaid customer service can provide more information if the claim denial is for a patient with a Medicaid managed care plan. If the patient has a commercial plan, information about the appeals process is available in the provider's policy/contract with the insurer.
Providers also may bring in a third-party healthcare attorney to respond to claim denials.
"To enhance your RCM processes and your patient experience, it is imperative that [the third-party attorney] know healthcare law, insurance coverages and benefit denials," said Mr. Sornberger.
If you would like to share your RCM best practices, please email Kelly Gooch at kgooch@beckershealthcare.com to be featured in the "RCM tip of the day" series.
More articles on healthcare finance:
Mayo Clinic's operating income dips 7.6% in Q2
Medicare overpaid millions for radiation therapy planning services, OIG says
More Americans turn to crowdfunding for medical bills: 6 things to know