Think of the number of times an insurance payer denies payment. You did your research. You used the right CPT codes for the service provided. You reported the necessary additional information, such as the referring provider. You know it was posted within timely limits. You know the facts. It should not have been denied. 

As an experienced biller, you know that it ought to be paid. So, you call the insurance payer again. And the payer denies you…again.

At that moment, it’s natural to second guess yourself and simply give up and let it sit in the aging claims file. But a biller is in the business of getting bills paid. That means not giving up. 

Here are a few things to keep in mind when you face insurance payer denials—so your aging claims don’t stack up.

Insurance Payers Are in the Business of Denials

Knowing this simple truth can help you reframe payer denials. You actually should expect denials. Also, because payers are in the business of denials, don’t expect them to provide unsolicited help.

In fact, payer customer service reps are notorious for being vague in their responses when you inquire about a denial. Expect this. They don’t want to tell you exactly what you need to do for them to issue payment. If they can get around paying, they will. And this starts with not giving you any tips.

That is why it is important to fully understand payer guidelines and policies around the service being billed. To avoid any potential reason to cause a denial, make sure you are adhering to those guidelines with clean claims prior to submission.

They Don’t Know More Than You Know

Really, they don’t. They are in a position of power—holding the purse strings, so to speak—but you can flip the power structure by thoroughly understanding guidelines. You don’t have to accept whatever the payer says to be correct. More often than not the denial is a result of an internal processing error or is an invalid denial on the payer’s end. 

Billers should be confident in holding the payer to the same guidelines you are held to. 

Recently, I inquired about a claim denial and medical CPT, which should have been covered under the plan. The payer customer service rep generically replied, “Well, the diagnosis doesn’t match the CPT.”

“But it does,” I said. “Per your guidelines, it states this is a covered procedure when reported with XX diagnosis code, and it does not list any exclusions to this. Can you please provide more explanation as to why this claim is being denied if the criteria match your guidelines?” 

If all the criteria match the guidelines and the payer cannot provide any additional information to support the denial, it should be escalated as an appeal, and then a 2nd-level appeal, until either it is resolved or the payer provides clear documentation of why the denial is an exclusion to a particular policy. 

Flip the power structure with knowledge. Fight for what you are owed, and stand firm knowing everything on your end is correct.

How You Talk to the Payer Matters

It’s tempting to be short—even rude and argumentative—when speaking with a payer customer service rep who is particularly unhelpful.

You can maintain a level of professionalism by being specific and prepared. Specifically, anticipate the vague answers a payer might respond with and formulate a few follow-up questions in advance. This will make the conversation more focused on details and, therefore, more productive.

For example, prior to calling on a claim that has been denied for a non-medically necessary diagnosis, pull up the payer’s policy on the CPT code so you can reference it directly. Some payers will have their own medical policies on their websites. Others will follow the Medicare LCDs and articles for coverage. Know which applies in your particular situation, and be sure to have it pulled up when you call the payer.

Though you should maintain confidence that the claim is correct per the payer guidelines, do not go into the call with an adversarial mindset. Keep your tone of voice warm, and remember, “Thank you,” and “I appreciate your help”, can warm up even the chilliest of reps. 

The point is, if you are in the right and you have adhered to the guidelines and policy set forth by the payer, stand your ground, diplomatically push back with proof, and keep chasing the claim until it is resolved. Be tenacious. You’ve got this.

For more tips, download Breaking Down the Components of AR into 6 Easy Steps”

By Amanda Kissinger, RevCycle Partners Billing Service Group Manager