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Insurance Company Denials: Fighting for Your Fees

Posted On December 16, 2013
December 16, 2013

Insurance Company Denials: Fighting for you Fees

Recently, I spoke with a physician that had in the past performed the same procedure our team of physicians at Sleep Apnea Treatment Centers of America have optimized, i.e. radiofrequency ablation (RFA) of the tongue. I was excited to learn about his experience and long-term outcomes. However, this physician mentioned that he abandoned the procedure not because of its results, but the fact that insurance companies denied and refused payment for a procedure listed as medically necessary. Unfortunately for patients and physicians alike, this is not a random occurrence.

Due to denied insurance claims, physician practices lose a significant amount of administrative time and revenue. According to Department of Labor estimates, each year over 1.4 billion claims are submitted with employer-based health plans but an estimated 1 of every 14 claims (or approximately 100 million claims) are initially denied.

Industry experts say the top three reasons for denial are patient ineligibility, medical necessity and coding errors. However since 2010, the American Medical Association estimates that more than $210 billion could have been saved if commercial insurers had consistently and correctly paid claims.

There is no justification for the current complex health care billing, payment and claims reconciliation process that costs physicians 10-14% of their total revenue just to get paid. The lack of transparency of the current system has led to an unhealthy distrust between physicians and payers.

Here are some ways you can start today to reduce and correct denials:

  1. Conduct monthly, quarterly, and yearly claim review analysis to determine where the error was made, if there is a pattern of remark codes, and how the issues can be corrected.
  2. Before scheduling initial appointments and consults have your front office contact the payer for eligibility verification.
At Sleep Apnea Treatment Centers of America (SATCOA), our Medical Billing Department coordinates the health care billing, payment and claims reconciliation process for each of our physician partner practices. Our Medical Billing team has the luxury of focusing and becoming experts with one CPT code, CPT 41530.

The majority of our patients are acquired via SATCOA’s direct-to-consumer marketing efforts. While a prospective patient is on the phone speaking with one of our medical concierges, he or she is seamlessly sent to SATCOA’s Medical Billing Department for real-time insurance verification and pre-certification. By using all electronic transactions, our physician partners are eliminated from many of the manual daily processes, so more time can be spent on direct patient care. Our Medical Billing Department has decades of experience in experimental and conventional medical billing and have been over 97% successful overturning denials for coverage.

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