Tips For Appealing Midwife Claim Denials

A health insurance denial happens when your health insurance company refuses to pay for something. If this happens after you've had the midwifery service and a claim has been submitted, it's called a claim denial. Insurers also sometimes state ahead of time that they won't pay for a particular service, during the pre-authorization process; this is known as a pre-authorization--or prior authorization--denial. In both cases, you can appeal and may be able to get your insurer to reverse their decision and agree to pay for at least part of the service you need. There are literally hundreds of reasons a health plan might deny payment for a healthcare service. Some reasons are simple and relatively easy to fix, while some are more difficult to address.

Why Would a Health Insurance Claim Be Denied?
A health insurance company may deny a claim for many reasons, including:

• The treatment or service isn’t deemed medically necessary or appropriate.
• The plan doesn’t cover the treatment, service, medication or goods.
• The health care provider isn’t in your plan’s network.
• Your insurer requires preauthorization or a referral from your primary care physician.
• The treatment is considered investigational or experimental.
• Your coverage has lapsed or you aren’t enrolled with the insurer any longer.
• A paperwork or data entry error prevented the claim from being processed correctly.
• The claim wasn’t filed on time.

As a maternity care provider, claim denials are pain in the butt. Even practitioners who take precautions to avoid insurance payment pitfalls sometimes find themselves faced with a claim’s denial. Handling denied insurance claims can be a frustrating, time-consuming and complicated process for practicing psychologists and their administrative staff. Knowing some basic strategies for resolving claims denials can save practitioners time and improve their practice’s cash flow. Some basic pointers for handling claim denials are outlined below.

1. Take the time to review all notification regarding the claim  Although it sounds obvious, this is one of the most critical steps in claims processing. You should carefully read any notification you receive from an insurance company about a claim. Notifications should state whether the claim has been paid in full, partially, delayed or partially. If the claim is deemed "unclean" or contestable, the carrier will provide instructions on how to resubmit the claim with any missing or corrected information.  In the event that the claim is not paid in full or denied for any reason, the notification must state the reasons and the procedures and documentation needed to resubmit or appeal the claim.

For more information, contact the carrier if the notification is unclear. You may discover that the claim was incorrectly adjudicated by the payer, in addition to the stated reason for denial. It is possible that your submission processes do not meet the requirements of the payer. However, you may be able to make simple changes to improve your claims submissions.

2. Be persistent
If you feel the insurance provider has wrongfully denied your resubmitted claim, you can appeal. You should be clear about what information you must include with your appeal. Keep in mind, appeal procedures can vary depending on the state law and insurance company.

An explanation of your appeal and any supporting documentation such as a copy of the claim, and copies of communications to the company regarding the matter, should be included in your appeal. Additional information may be required to prove medical necessity if your claim is denied. It is important to comply with your obligations under the Health Insurance Portability and Accountability Act, (HIPAA), to protect psychotherapy notes and provide only the "minimum required" information.

Sometimes, you may have to submit the claim again or appeal multiple times to reverse an insurance company's decision. But don't lose heart. The insurance company will appreciate your persistence in resolving the issue and getting paid.

3. Don’t delay
It is crucial to submit and resubmit claims within the deadlines specified by the company, or any applicable laws in your particular state. If you don't, your claim could be dismissed based on information already provided.

4. Get to know the appeals process
Make sure to familiarize yourself with the appeals process of your carrier before you file an appeal. You will be better equipped to respond to your carrier's actions if you have a good understanding of their policies. You should keep current information about the appeals and claims adjudication processes for every carrier you work with. This information is often available on the websites of carriers. If applicable, you should also keep hard copies of it whenever you sign a contract.

5. Maintain records on disputed claims
Keep a written record of all information that you receive from an insurance company regarding a claim. Also, make sure to include the name and contact information of the representative you spoke with. This information should be kept with key information about your claim such as the reason the claim was delayed, partially paid or denied, the actions taken by your office to follow-up on it, and the final outcome.

These records could be used to help you in the future, whether it is to appeal to higher levels or to complain to the state insurance commissioner. These records can be used to help your office avoid or resolve future claims denials.

6. Remember that help is available
Although handling claims denials is frustrating, it can help you save time and money by alerting to the expectations of the insurance companies you contract with. You may be able to reduce rejections and denials by ensuring your billing procedures conform to the requirements of the company. If you have any reimbursement issues with an insurance company, please contact your state insurance commissioner for assistance.

Insurance denials are very frustrating. It will give a huge impact to your practice if you are not mindful enough of every action you take. But it is preventable if you collect the right information and verify it thoroughly. 

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References

American Psychological Association. (2005, March 1). Six tips for handling insurance claim denials. https://www.apaservices.org. Retrieved November 28, 2022, from https://www.apaservices.org/practice/business/finances/insurance-denial 

Martin, E. (2022, November 16). How to appeal a health insurance claim denial. Forbes. Retrieved November 28, 2022, from https://www.forbes.com/advisor/health-insurance/appeal-health-insurance-claim-denial/