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Claims Processing: Could My Claims Be Returned by the Insurance Company? Why?

Health Insurance Denied Form Showing Unsuccessful Medical Application

Claims can be returned for a variety of reasons. The most common cause for a rejected claim is missing or inaccurate information. For example, errors in patient data such as the date of birth, age, sex, address, or name will cause an immediate return. Then there is provider information and insurance identification numbers, which can be easily and unintentionally misrepresented.

When the insurance company payer receives a claim, they check to make certain the patient is covered by the policy and all treatment codes match the appropriate diagnosis. Sometimes preauthorization records, referring physician identification numbers, or evidence of medical necessity is left incomplete.

The use of a medical claims processing software ensures all required information is included in the claim, prior to submission to the insurance payer. The software will catch any obvious errors such as missing or invalid information easily. The best way to increase claim payments is through prevention, submitting a clean claim the first time without any errors.

A medical billing software solution is well worth your investment. Apex EDI wants to simplify claims processing for you, so you can get paid faster. Contact Apex EDI to watch a free demonstration of our software today.

Posted in: Claims Processing

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Insurance Claims: Tips for Negotiating Claims with Insurance Companies

Negotiating an insurance claim

When healthcare providers and staff understand how to communicate with insurance companies, it can make billing and medical claims processing much easier. It’s not uncommon for an insurance adjuster to offer an initial settlement at a lower amount than you requested. Negotiating a final settlement can have a positive impact on your business.

It’s imperative to first determine what you believe your medical claim is worth and decide on a minimum settlement figure that you will accept. When you receive an offer that seems low, ask the insurance company to give you specific reasons why the offer is so low. Then follow up by writing a brief letter responding to each of the facts the insurance company mentioned.

It’s also helpful to mention emotional suffering the patient

experienced in your letter and conversations. There is no way to put a dollar value on life changing health issues and they can be a powerful way to influence a higher settlement. For example, you may want to include a photo of a severe injury and mention the impact on the patient’s ability to perform daily work or life routines.  

During the negotiation process, if the insurance company provides some facts that you had not considered, you may have to lower your figure a bit. Typically within two to three conversations you can agree to a settlement amount somewhere in between your desired payment and their offer. Once you reach an agreement, follow up with a short letter confirming the amount offered.

Remember it’s not advisable to take the first offer you receive from an insurance carrier, even if it is reasonable. It always helps to make a counteroffer that is fair. During a phone call with the insurance adjuster, you can discuss the strengths and weaknesses of your claim. With a little bargaining, you can often get to an agreement that is better than the initial offer and satisfies both of you.  

Submitting medical claims and negotiating settlements with insurance companies is a process that Apex EDI knows and can help you with. We want to make sure your practice thrives and that you receive the maximum payment you are entitled to. Contact Apex EDI to request a free demonstration of our medical billing software today.

Posted in: Insurance Claims

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