Why Appeals Process is tricky in Healthcare BPO Companies

If healthcare bpo companies does a better job in appeals process, healthcare professionals and organizations can be trouble-free from revenue loss. Even though medical billing is quite complicated involving many processes, timely and accurate payments are very crucial.

Healthcare Bpo companies are medical billing specialists where they understand payment responsibility, evaluate their insurance policy, arrange their billing forms and collect revenue payments from insurance companies.

The total process starts with an appointment scheduled with healthcare professionals to revenue reimbursements from the insurance companies.

An appeal process is used when the insurance companies disagrees with the service provided and halts the reimbursements without proper reason stated. Most of these appeals processes result after claim denials and rejections.

Reasons for claim denials before an appeal:

  • When a patient enrollment is not proper in the insurance plan or with the payer.
  • When a particular medical service, procedure or treatment is uncovered.
  • When pre-certification is not filed. Sometimes insurance companies will require the details of ambulatory surgical center used before medical services. If pre-certification is not provided, the claim can be denied or payment can be reduced.
  • When adequate documentation is not produced to support the reason of performing medical procedure.
  • Invalid reference numbers on the files.
  • Inaccurate patient demographic details. Errors in procedure code, age, and name and ID number can also be reasons for denials.
  • When failed to submit required documents to the insurance companies.

Usually healthcare Bpo companies take the responsibility to spend time for appeal processing when a claim is denied.

This procedure or process helps in recouping healthcare professional’s revenue and also avoiding problematic claims from the auditors.

If healthcare Bpo companies fail to appeal the denied claims, then it indicates auditors that healthcare professionals are not aware of the compliance problems and inaccurate billing. Therefore, they aren’t proactive in correcting their errors.

Steps to appeal denied claims:

  • Make a call to the insurance companies. Often many claims are denied cause of errors in simple codes that doesn’t give accurate information for declining revenue payments.
  • A call to the insurance companies can clarify the doubts involved and reason for claim denials.
  • While making a call with the insurance companies, make sure to record the date, name of the insurance company and representative, and reference number.
  • The reference number will speed up the process especially when multiple calls have to be made during an appeal process.
  • Use an accurate claim number on a corrected claim; otherwise the claim will be pushed into duplicate claims.
  • Have a plan for the appeal process. It’s not an easy task to appeal every claim that’s denied. So, maintain a strategy for the appeal process.
  • Concentrate on high value claims than the lower ones.
  • Differentiate the claim denials. Differentiating or categorizing the claim denials helps to identify the patterns and streamline the appeal process.
  • Healthcare Bpo companies develop their own strategies and document the way each type of denial is appealed especially according to insurance companies requirements.
  • Appeal letter: Standard appeal letters are available on insurance companies websites for denied claims related to invalid medical codes, inaccurate patient demographic details.
  • While filing standard appeals, vital information such as type of service provided and data of the service rendered should be clearly mentioned.
  • For the rest of the denials related to medical necessity, customized appeal letter is necessary and required.
  • By mentioning CPT guidelines and insurance payer’s guidelines in the appeals processing letter, it can help process the claims faster.
  • In case if the appeals letter does not provide the required information, then the process might prolong and becomes a hard job for healthcare bpo companies.
  • Appropriate documentation is required. The documentation must include the information related to claims process. The details should be relevant and limited. If the information is more and is not relevant, then it might count as HIPAA violation.
  • Healthcare Bpo companies must have experts in dealing with the appeals process and should be experienced in medical billing and coding processes. Such teams can manage and supervise appeals processes and also can contact insurance companies directly.
  • Prepare a contact list. Healthcare Bpo companies and healthcare professionals will have set of contact numbers for different insurance companies and responsible for answering the questions at payer’s office.
  • Have regular follow ups with the claims and set alerts and reminders to follow up. This will prevent the claims from getting denied or falling into loss.

Resubmission of a Claim:

  • A claim is resubmitted when it’s originally denied due to inaccurate information, missing documentation, inaccurate coding.
  • Resubmission of claim happens by correcting the inaccurate information with appropriate details and filing them within the limited time.
  • While resubmitting the claims, the billing team should include necessary information.
  • It should contain an updated copy of claim along with the original claim copy.
  • A copy of remittance advice on which the claim denial took place and was incorrectly paid.
  • All the required documentation by the insurance companies.
  • Identifying the claims with the word resubmission on it.

Steps for an appeal process:

  1. Call the insurance companies and get clear information for the denied claim.
  2. Request for a formal fair, clear review of the claim and reason for denials.
  3. Consider a legal action by filing an appeal with the required documents to get revenue reimbursements for the denied claims.

Appeals process can be very tricky if not properly implemented. Claim denials may halt revenue payments and if proper appeal process is followed by healthcare BPO companies, revenue reimbursements can be guaranteed with no doubt.

Advantages of Healthcare BPO Companies:

While there are plenty of resources available to get the appeals process right, you need the correct solution that will help you get the claims right in the fastest way possible.

  • Even if you have an expert in-house team, the professionals usually work on different things at the same time. They have too many responsibilities to take care of a single task.
  • With healthcare BPO companies, you will have dedicated teams to get your work done.
  • Since they work with different kinds of facilities, they come in with a lot more experience.
  • They also handle accounts for different specialists. Therefore they have proven models to approach every specialty to make sure that your claims are approved on time.

Hope you got information about starting an appeal process. For more suggestions, please comment below. We will consider them if relevant to our blogs. For more queries and updates on healthcare, please subscribe to our blog.

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