Insurance Claim: How to Handle and Appeal

Insurance Claim: How to Handle and Appeal

When a reimbursement denial is received, medical insurance billers (MIBs) may need to initiate an appeal process to collect disputed funds for practitioners. In this informative article, Nitin Chhoda reveals the most common reasons for denials and the best strategies for handling claim disputes.

insurance claimEach insurance claim goes through an adjudication process at a clearinghouse to check the data for errors before forwarding it to the appropriate insurance carrier.

An insurance claim examiner conducts another exploration of the claim and renders a decision. The examiner can choose to pay the billed expenses, reimburse at a reduced rate, or deny the insurance claim.

Insurance carriers usually deny payment for one of six typical reasons. Some of the factors are the following:

  1. Carrier’s procedures
  2. Medical necessity
  3. Inactive policies
  4. Out-of-network
  5. Level of care
  6. Pre-existing conditions
  7. Pre-authorization

Unknown Carrier’s Procedures

MIBs should be aware of each payer’s procedures and policies for handling claims. Each insurance company has its own hierarchy and protocols for reviewing an insurance claim.

MIBs should also check the contract between the clinician and the insurance company to determine that all conditions have been met.

Medical Documentation is Necessary

When an insurance claim is denied on this basis, it’s up to the MIB to provide documentation, physical therapy documentation for example, that the appropriate diagnosis and procedural codes were employed. Sometimes a coding change and resubmitting the claim will result in a satisfactory resolution.

If the codes are accurate, a letter must be provided that clearly states why the treatment was necessary, along with any extenuating circumstances.

Patient’s Insurance Policy is Now Inactive

It’s essential that the MIB has proof that the patient has an active insurance policy at the time treatment was provided.

This can be accomplished through a copy of the individual’s medical card, a letter from their employer, or a statement from the insurer.

Out-of-Companies-Network of Physicians

Some carriers require patients to only see practitioners within the company’s network of physicians, but situations arise when an in-network clinician isn’t available.

A simple letter explaining, in detail, why the patient didn’t have access to the carrier’s network of clinicians can easily turn an insurance claim denial into a payment.

Having Too Much Level of Care

Insurance claim examiners may determine the level of treatment that was billed exceeded the usual care for a particular ailment. The culprit in insurance claim denial is usually a lack of documentation that fully explains why additional treatment or procedures were required.

Providing supporting documentation usually takes care of the problem.

The Most Common – Having Pre-Existing Conditions

Most insurance policies won’t cover treatment for conditions and diseases that patients were afflicted with prior to when their policy became active.

If treatment can be linked to any prior health problem, the need for an appeal is negated.

If it wasn’t related to a previous health issue, MIBs should provide a written explanation, accompanied in the insurance claim, as to why the ailment wasn’t related to a pre-existing condition.

Unable to Meet Pre-Authorizationinsurance claim

A wide variety of treatments require pre-authorization for insurance claim reimbursements. MIBs can reverse a denial if they provide proof the treatment would have been approved, as in the case of an emergency.

A convincing argument can result in full payment and waiving of penalties for not obtaining the pre-authorization.

An insurance claim denial doesn’t always result in an appeal.

Providing documentation and a convincing argument as to why the denial was in error is essential when disputing reimbursement rejections. Clear and concise communications are critical elements of strategies to obtain payment for denied claims.

Medical Coders – What are they?

Medical Coders – What are they?

Medical coding is often associated with medical billing, but the two are entirely different career paths. Coders use the information provided by the medical provider for treatment rendered and assign the appropriate codes for billing purposes.

The duties of a biller and coder may be combined in smaller practices and performed by the same individual. Nitin Chhoda shares the main responsibilities of medical coders and the attributes that they must have.

medical codersEducation Always Counts … Of Course!

A thorough knowledge of medical terminology and anatomy is essential for a medical coder. The average medical coder’s course is 15 months long and costs approximately $2,000.

Online training is available from a variety of professional organizations and at multiple colleges throughout the country.

A prerequisite is college-level human anatomy and physiology.

Students will learn how to assemble documentation and interpret guidelines for accurate coding. Courses will address the upcoming transition to ICD-10 codes, along with maintaining compliance and the ethical and professional standards required of a certified coder.

Medical Coders Must Be Familiar with Legalities

Remaining in compliance with government rules, regulations, guidelines and laws will play a major role in a coder’s every day duties.

Medical coders are in contact with confidential information that’s protected through regulations established by the U.S. Office of the Inspector General (OIG).

The OIG rules are designed to prevent fraud and abuse in billing.

Medical coders must also maintain compliance in the usage, dissemination and transmission of patient information as set forth in the Health Insurance Portability and Accountability Act (HIPAA). Known as the Privacy Act, it dictates how to handle sensitive patient data.

Medical Coders Know the Requirements and Compatibilities When Coding the Bill

An extensive array of data is collected during each patient encounter and it’s up to the coder to decipher any clinician notes and gather the documentation necessary to accurately code the reimbursement claim.medical coding

This is where knowledge of anatomy and medical terminology comes into play.

Medical coders are responsible for assigning the appropriate alpha-numerical CPT and ICD codes to reflect the practitioner’s diagnosis and subsequent treatment.

Medical Coders Should Be Familiar with an Integrated Software Technology

All the assembled data must be entered into a specialized medical billing software program or an electronic medical record (EMR) system in preparation for billing.

In practices that employ a single individual who acts as both the coder and biller, he/she will transmit the claim electronically to a clearinghouse for examination before being sent to the payer.

Show Me the Money …

Medical coders who undertake both coding and billing duties will be required to monitor claims to ensure they’re paid, follow up on late or denied claims, and interact with insurance carriers to collect the clinician’s fees.

Certified medical coders also work with patients on their portion of healthcare costs and file appeals with payers when required.

Medical coders hold considerable power within a practice and are professionals in a specialized field. They use their knowledge and ability to keep the flow of funds coming into a practice. They hold the financial keys to enable clinicians to plan, expand and pay the bills.

What are the Medical Billers?

What are the Medical Billers?

Medical insurance billers (MIBs) are the lifeline of a well-funded practice and the connecting link between patients, practitioners and insurance companies.

Billers affect the lives of hundreds of people each week and are an essential link in the reimbursement process. They collect payments for clinicians and ensure that insurance companies pay their portion of the costs for their clients’ healthcare expenses.

medical billerMedical billers perform a variety of functions, from entering the alpha-numeric ICD-9 and CPT codes that tell insurance companies the treatment a practitioner provided to interacting with patients on the balances they owe.

Medical billing staff works with sensitive data each day that requires confidentiality, integrity and ethics.

First Step — Data Collection

An MIB often functions as a coder and a biller, though the jobs can be exclusive of each other. Medical billers gather all the information associated with a patient’s encounter with their healthcare professional.

That information provides the documentation that will be used to support the payment requested from insurance carriers.

They decipher the data to determine the patient’s complaint and the appropriate CPT code to reflect the treatment provided.

Medical Billers Should Have Good Communication Skills

Medical billers spend a considerable amount of time interacting with others as part of the data collection and payment process. Clinicians must be queried to clarify patient encounter information and patients contacted about their payment obligations.

Medical billers also interact with insurance company representatives on reimbursement issues.

MIBs Must Always Verify the Facts

Medical billers are responsible for verifying patient insurance information, the correct billing format for each payer, and assigning the codes and modifiers that result in the practitioner’s payments.

They work with hard facts about patient policies, physician services and insurance company protocols.

Medical billers may also transcribe a doctor’s dictation about the patient encounter. Billers are knowledgeable in medical terminology, which helps them in assigning diagnosis and procedure codes.

Medical Billers Must Have Computers and Integrated Software

Medical billers spend a majority of their time behind a computer screen, ascertaining the facts of each patient encounter. They work with specialized billing software, like In Touch Biller Pro,or electronic medical record (EMR) systems, like In Touch EMR, that assist them in coding correctly, meeting the many submission demands made by payers, and transmitting claims electronically.

Consistent in Following Up Funds

Medical billers track and monitor each claim to determine its position within the reimbursement process. medical billers' software

They submit claims to clearinghouses where they’re examined for mistakes, errors and inconsistencies.

Clean claims are forwarded on to payers for reimbursement.

Medical billers track and monitor each claim to determine its status, ensure payments are made in a timely manner, and deposited in the practitioner’s account.

They work with clearinghouses and carriers if a claim is denied to obtain payment, and interact with patients on co-pays, deductibles and balances owed.

IMPORTANT:  Medical billers ultimate responsibility is to ensure that clinicians collect the maximum amount of money to which they’re entitled.

Medical billers wear many hats in their profession. They’re often one of the first and last individuals with which patients interact on financial obligations, and they comprise the key element in the reimbursement chain.

Medical billers document, code, transmit and follow payments to ensure their client’s financial status remains in the black.

Claim – How to Appeal When Denied

Claim – How to Appeal When Denied

Each reimbursement claim goes through an adjudication process once it reaches a clearinghouse and eventually, every biller will receive a denial.

Depending upon the reason, healthcare providers can appeal the decision and MIBs will play a major role in the process. In this enlightening article, well known physical therapist, Nitin Chhoda, explains how to resolve disputes without going through an official appeal.

claimMany claims are denied for oversights and mistakes that can easily be rectified. Winning payment for their clients requires MIBs to develop an appropriate strategy that addresses the cause of the claim denial.

The first step is a written communication that demonstrates exactly why the claim denial was made in error. The following are some important factors to consider when appealing a denied claim:

  • Active policies
  • Improper submission
  • Level of care
  • Medical necessity
  • Networking problems
  • Pre-authorization
  • Pre-existing conditions
  • Procedures that are not covered

Proof the Patient’s Policy is Active and In Effect

When new insurance coverage goes into effect, the information may not have been added to the clearinghouse database. Proof must be provided that the patient’s policy was active and in effect at the time of treatment.

This can be accomplished with a copy of the valid insurance card or a letter from the patient’s employer that provides the pertinent information.

Adhering to the Payer’s Reimbursement Submission

Each claim undergoes close scrutinization. Individual insurance companies have their own policies, procedures and protocols for reimbursement submissions.

Not adhering to these will generate a claim denial, but can generally be fixed by correcting any error or making the appropriate revisions and resubmitting the claim.

Required Level of Care

A carrier may decide the level of care exceeded what was required. Supplying supporting documentation for the claim will usually clear up the matter.

Is the Medical Necessary?

It’s the responsibility of the practitioner to prove through appropriate documentation that the treatment or procedure provided was medically necessary. The clinician must provide a written letter that explains any extenuating circumstances.

Network Unavailability

Payer policies may require patients to only see specific practitioners within their network of participating providers for treatment to be covered. Clinicians need to explain if an in-network provider wasn’t available.

Circumstances of Missed Preauthorization

If a preauthorization wasn’t obtained prior to treatment, explain to the payer the circumstances that prevented the request, such as a medical emergency. The clinician should also supply evidence that the authorization would probably have been approved anyway.

Pre-Existing Conditionsclaim denial

Many policies have exclusions for any disease or condition that affected the patient prior to when their policy went into effect.

To eliminate a claim denial, the onus is on the medical provider to demonstrate that treatment wasn’t due to a pre-existing condition.

If available physical therapy documentation doesn’t support this, an appeal is futile.

Procedures Covered or Not Covered

Each insurance policy has specific restrictions, requirements and limitations. MIBs will need to ensure that the claim was coded correctly and the procedure was covered. If the coding was accurate but proof of coverage can’t be assembled, don’t appeal.

An appeal isn’t always indicated when a denial is received. When all the requirements, coding and conditions of the policy has been met and a denial is issued, it’s important for the MIB to provide the needed documentation and evidence to support the reimbursement.

These strategies provide carriers with clear and logical explanations as to why the denial should be removed and funds facilitated to the practice’s account.


Billing and Coding Errors – How to Minimize If Not Avoid

Billing and Coding Errors – How to Minimize If Not Avoid

The Affordable Health Care Act resulted in many changes for subscribers and alterations in the services carriers are willing to cover as part of insurance policies.

Those modifications directly impact how medical insurance billers (MIB) code claims. To assist billers in avoiding costly billing and coding errors, Nitin Chhoda examines the most common reasons for claim rejections and denials.

codingTo make payroll or purchase equipment and keep a practice operational, clinicians rely on MIBs to provide a steady stream of income in the form of reimbursed claims.

When the flow of revenue is interrupted with rejected or delayed claims due to coding errors, it can spell hardship for the practice and result in an investigation by regulators and law enforcement for suspected fraud.

Assumption of Coding

Every patient encounter is different and MIBs should never code on the assumption that “standard” treatment was provided. Billers need to consult with the clinician if they suspect missing information or simply can’t read the physician’s handwriting.

Documentation Problems

A number of documentation problems can arise when claims are filed, including missing or incomplete documentation that supports each item for which the practitioner is seeking reimbursement.

A criminal investigation could be done in the immediate future if a payer believes the MIB altered or recreated documentation to support a denied claim.

Mismatched Coding

The incidence of mismatched coding is a careless mistake and happens more often than one would imagine. It most frequently displays as billing a male patient for a treatment or procedure that is unique to female anatomy.

Important note: You can never overlook such simple mistakes because it can lead to claim denials.


Each insurance carrier establishes its own set of rules and regulations governing claims. Billers can expect a denial if they don’t adhere to the payer’s specific policies, procedures and protocols.


MIBs who fail to obtain the appropriate approval prior to treatment will find the practitioner’s claim denied. Payers are sometimes willing to make the approval retroactive in the event of an emergency when treatment was critical to save a person’s life.

Truncated Coding

Claims must include all three diagnosis levels for the greatest accuracy. Truncated coding may address the manifestation and episode of care portions, but not include the site of infliction.

Up and Down Coding

Coding at a higher level of treatment than was received exposes practitioners to fraud charges. Down coding is billing at a lower rate than appropriate in an effort to avoid denials. Payers who suspect this of happening can hold up claims for weeks or months.coding and billing


Coding is designed to include multiple actions as part of specific procedures and is billed as a whole. Unbundling bills those elements separately and could be viewed as an attempt at fraud.

Practitioners place their faith in MIBs to do their jobs quickly, efficiently and ethically. Mistakes in your physical therapy billing and coding can be easily rectified by simply double checking each claim before transmitted.

Being “creative” by unbundling or making assumptions about treatment that’s not supported by documentation can lead to charges, fines and litigation against both the clinician and the biller. Taking an extra moment to examine the claim will save days or even weeks in terms of delays and denials.

The Real World of Outpatient Claims

The Real World of Outpatient Claims

Medical insurance billers (MIBs) learn a wide variety of skills and obtain a diverse array of knowledge in preparation for a career as a biller. Conditions and protocols in the work environment can vary significantly from the educational arena, depending on the facility’s policies. In this informative article, Nitin Chhoda takes a look at the real world of outpatient claims.

outpatient claimsNew Beginnings

An appointment for a new patient begins with a comprehensive health form to collect as much information as possible about the reason for the visit, along with health concerns, conditions and ailments.

The outpatient claims process include obtaining a copy of the individual’s photo ID and insurance card to verify eligibility and that the policy is valid. Healthcare identity theft is an increasing problem and MIBs must be vigilant.

As part of the registration of the outpatient claims process, MIBs review the guidelines and specifics of the patient’s policy.  Exclusions, limitations and prerequisites may apply that can affect available treatment options and the timely collection of the provider’s revenues.

Co-pays and Deductibles

Patients are typically required to pay a portion of their healthcare costs through co-pays and most policies have a deductible that must be met. Part of the outpatient claims process includes collecting the required co-pay, preferably before the patient sees the provider. Insurance data is presented to the practitioner, enabling him/her to render care that meets with the carrier’s policy specifications.

Just the Facts

In the world of outpatient claims, the facts encompass the provider’s diagnosis and statement of services provided. MIBs assemble all the necessary data and documentation, assigning numerical and alphabetical codes that will be used for reimbursement purposes when the claim is transmitted to the clearinghouse.

Follow Up Visits

outpatient claims processContinuing care isn’t just for patients. MIBs monitor and track claims, outpatient claims included, to ensure they reached their destination and determine the payment status. If a problem arises, billers will need to conduct a follow up and revisit the claim to rectify any errors or obtain payment.

MIBs are also responsible for contacting patients for unpaid balances on their accounts. When patients have difficulty paying their bill, MIBs may be authorized to negotiate payment plans or turn the account over to a collection agency.

In the real world of outpatient claims, the expertise of the certified medical insurance biller is a key element in the financial success of a practice.

Medical billing people are the keepers of the data and outpatient claims procedures that facilitate the flow of revenues to practitioners, forging the essential monetary links between patients, practitioners and payers.