Refiling Claims Pays Off

By Jane ehrhardt

Change Healthcare found that 86 percent of claims denials are likely avoidable, according to their 2020 Revenue Cycle Denials Index. It also found that providers do not resubmit 65 percent of denied claims.

“The biggest problem with most groups we see is the follow-up after the payment comes in from insurance company,” says Bill Cockrell with Medical Billing and Consulting Services (MBCS). “The payer might only deny a portion of the claim, rather than the whole thing; or maybe they didn’t pay the claim in full. Just because they say it’s not payable, doesn’t mean it isn’t something fixable.”

With the claim, the insurer includes an explanation of benefits that states the doctor’s fee schedule for the services, the payer’s fee schedule, what the patient is responsible for, and then the contractual adjustment because of the billing agreements between the provider and the payer. For instance, a doctor may charge $100 for an office visit, but the fee schedule with the payer is $75.

“So if the claim was filed correctly, the physician should get $75 minus the patient copay,” Cockrell says. “If the payer doesn’t pay that full amount, there has to be a reason, and that shows on the explanation of benefits as a rejection code. Some groups always write off that unpaid difference rather than refiling.

“But that write-off could be lost revenue from something as simple as resubmitting with a corrected or missing modifier that would rectify the insurer’s fee. Or it may only need the submission of a missing piece of documentation.”

The contractual adjustment — the difference between what the healthcare provider charges and the agreed-upon amount the payer will reimburse — are an unavoidable write-off. Some practices staff a clerk to review claims and write off these contractual adjustments. “What we see happen is some groups just write off everything the insurance company didn’t pay,” Cockrell says. No reviews, no refiling.

Sometimes the write off happens simply because the clean claim window closed, which generally allows a minimum of 90 days up to a full year, depending on the insurer. “We see that more often than you could believe,” Cockrell says.

The unchecked write-offs often become the norm rather than a stopgap. “The group becomes comfortable doing that because sometimes they don’t have time to deal with it,” Cockrell says. “If you don’t write it off and don’t do anything else with it, your accounts receivable isn’t realistic. It’s not reflective of