Claims and Appeals Best Practices

As a medical practice, you must be well-aware that insurance companies do not always pay every claim for the agreed upon rate, for various reasons. In case of denials or underpayments, it is best to identify whether the claims need appealing. Since appealing is a lengthy process, the following should first be considered.

Correct Billing

Claims denials are the result of data entry errors. Before appealing a claim, check whether the claim was billed accurately and correctly the first time.

Common data entry denials might be due to :

  • Incomplete or inaccurate patient information
  • bundling denials due to incorrect modifier usage
  • missing information
  • inappropriate modifiers used
  • mismatch between the CPT and diagnosis used

CPT Guidelines

CPT guidelines compliance may not always be easy to achieve. Insurance companies are not required to follow nationally recognized guidelines now. So, accurate claims are even more important now. If you are sure that the claim was billed correctly initially, check the insurance payor’s provider billing or administrative guide.

Payer-Provider Contract

Check whether contracted services are being billed appropriately. If contractual procedures are not being followed, then it may not be possible to appeal a denied claim.