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.


Claims:  Stepping into the 21st Century with Computerization

Claims: Stepping into the 21st Century with Computerization

Computerization is no longer a luxury for a medical insurance biller (MIB). It’s a necessity that enables billers to handle hundreds of reimbursement claims each week and keep revenues flowing to their clients’ accounts.

In this insightful article, Nitin Chhoda outlines the benefits of electronic medical record (EMR) technology for the 21st century billing business.

claimsSimply put, computerization is the process of electronic recording, storing and retrieving of data.

Billing software and integrated EMR systems are available and both offer electronic medical billing and claims management abilities.

The primary difference is that billing software can cost hundreds and even thousands of dollars, while EMR systems can be obtained from reputable vendors for free.

Meeting Mandates

Computerization is necessary under the Affordable Health Care Act to participate in government operated health insurance programs and submit claims to commercial insurance carrier clearinghouses.

EMR systems also provide the mandated security safeguards required by HIPAA for the transmittal of patient information.

Ninety-eight percent of government claims are reimbursed within 30 days with EMR technology and reduces the turnaround time with commercial insurance carriers to as little as 10 days. EMRs encompass a variety of measures to ensure security for authorized personnel, from passwords and time stamps to biometric recognition protocols. Payments can be posted and patient accounts monitored for amounts owed.

Paperless Documentation

Computerization allows MIBs to assemble a complete record of a patient’s diagnosis, treatment and procedures without the use of paper records. Documentation is gathered for every step of the patient encounter and the data is stored electronically where can be accessed whenever needed.

Information data, including claims, can be stored on the computer or in the cloud, and paper reports can be printed when necessary.

An EMR allows users to import written forms and documents into the software program for storage. The software can be utilized with desktop computers, laptops and tablet technology. MIBs can work from any location where a high-speed Internet connection is available, providing billers with the freedom to work from virtually any venue.

No More Excuses

Insurance companies can no longer claim they didn’t receive the necessary documents in an effort to delay payments. Clearinghouse computers automatically send billers notification when claims are received. Billers can use their EMR to track, monitor and manage claims throughout every step of the payment process.

Customization and Coding

claims reimbursement

Custom documents can be created within EMRs to satisfy the individual requirements of each insurance carrier.

Claims reimbursements depend on the proper coding and EMRs are able to handle the transition to updated ICD-10 codes with ease.

EMR technology facilitates the claims process for billers and meets all the requirements for the secure transmittal of patient information.

The technology provides a full level of computerization for every task a biller undertakes. The software systems eliminate paper records and offers portability, enabling billers to expand their repertoire of claims services and open up on-the-go opportunities.

EMR:  Electronic Claims Are No Longer the Future But the Present!

EMR: Electronic Claims Are No Longer the Future But the Present!

Medical insurance billers (MIBs) once dreamed of a modern way to submit claims that eliminated paper records and allowed claims to arrive almost instantly at their destination.

With electronic medical record (EMR) technology, the future is now. In this informative article, EMR expert, Nitin Chhoda, explains what billers need to know about electronic claim software.

EMRMIBs have the option of purchasing billing software or an EMR for their company’s needs. EMRs offer a wider range of functionalities for use in the 21st century medical billing enterprise.

Modern and convenient, they provide the critical security measures and protections mandated by HIPAA for the transmittal of reimbursement claims.

Counting Costs

Medical billing software costs range from $500 to $5,000. EMR technology can be obtained from reputable sources, with monthly user fees as low as $49. Both types of software systems accomplish the same objective, but EMRs offer other functionalities that can make a biller’s job easier and enable them to offer additional services.

Claims and Security

The Affordable Health Care Act mandates that billers submit reimbursement claims electronically. Claims that aren’t will be denied. Submissions must also conform to HIPAA security regulations for transmitting medical data. EMR software complies with both of those goals, has built in safeguards to protect patient information, and will alert everyone within the network in the event of an attempted breach.

Coding and Billing

The upcoming transition to ICD-10 codes has many in the medical field concerned about revenue disruption. Electronic medical records are capable of handling the addition of all the new codes and insurance plan modifications with efficiency and finesse, including those used outside the U.S. Most billers won’t encounter the foreign coding, but an EMR allows MIBs to be prepared.

Billers must implement HIPAA’s 5010 transaction standards for digital transmissions before utilizing the new codes.

Document templates can be created for any practice or specialty with an EMR, and can be modeled on documentation with which staff members and billers are familiar. The systems can be integrated with other clinicians, pharmacies and medical facilities for referrals, prescriptions and diagnostic testing. The full complement of documentation is available to billers for clean claims that are approved quickly.

Modern CommunicationsEMR system

Many billers are tasked with monitoring and tracking the financial accounts of their clients’ patients.

An EMR allows MIBs to communicate with patients through multiple means that includes phones and mobile devices, mail and email, and text and voice messages.

MIBs can remind patients about outstanding balances and monitor if deductibles and co-pays have been met.

Electronic claims are no longer a futuristic dream. They’re available now with instantaneous and secure transmissions that conform to the Affordable Health Care Act and HIPAA.

The multi-functionality of EMR software allows MIBs to painlessly integrate the new ICD-10 codes, collect client revenues quicker, and offer all the services practitioners require.

Medical Insurance Billers: How to be Better in Business

Medical Insurance Billers: How to be Better in Business

Every entrepreneur dreams of launching a successful business, but many are at a loss once the goal has been achieved. Medical insurance billers (MIBs) may be tempted to rest on their laurels once they’ve made it to the “big leagues”. In this revealing article, Nitin Chhoda provides medical insurance billers with helpful advice when they’ve outgrown their home-based business.

medical insurance billersIt’s easy to let day-to-day operations slide a little in the excitement and chaos of moving to an outside office.

Joining the ranks of highly visible businesses means medical insurance billers will need to work twice as hard and employ every tool at their disposal to attract and retain new clients.

Location Isn’t Everything, But It Helps

It’s tempting to rent office space in a highly visible venue, but it may not be the best solution for the budget. Discount pricing doesn’t necessarily mean a low-rent district. It’s possible to strike an equitable deal for space in under-utilized structures.

Many business owners are choosing to rent a home to house their enterprise. It can offer a cost effective solution that provides a user friendlier atmosphere. Medical insurance billers that take this route should check local laws and ordinances to confirm they can legally conduct business from the location before committing to a specific property.

Appearance Counts

The face a business displays to the public has a significant impact on clientele. Potential clients that see a structured and organized office will perceive the business as professional and the medical insurance billers as someone who are efficient and get results.

Accommodate the Customer

Business expansion dictates that the MIB assume new clients and that may necessitate moving out of their comfort zone to land new accounts. They may be asked to provide services not currently offered. Medical insurance billers should always be willing to learn new things and do whatever is necessary to accommodate clients.

Medical insurance billers should endeavor to provide the customer with what they want, as long as they have the appropriate professional skills and knowledge to do so.

Growth and Expansion

Medical insurance billers typically move out of their homes and into the public domain when their customer base will support it. Beware of rapid expansion and acquiring too many new clients. The result is an MIB that feels overwhelmed, with the inability to provide each client with the personal attention they deserve. An over-abundance of work entails hiring additional staff that may require significant training.

Be realistic when planning goals and anticipating revenues. Always expect the unexpected, from replacing equipment and hiring staff to unforeseen accidents. Medical insurance billers may need to increase their rates, but use caution or run the risk of losing even established clients. Think quality, not quantity.

MIBsThe Little People

Being charming, gracious and accommodating is easy when physical therapy billing business owners are seeking their first clients.

The same rules apply when medical insurance billers are at the helm of a growing enterprise. No business owner should ever forget the individuals, clients and subsequent referrals that helped them reach their current level of success.