Are you getting denials for the same reasons most of our clients are?  This is the follow-up to the previous post titled “Controlling Managed Care Denials – Part 1”, where we covered some of the proactive steps you can take to ensure your claims have the best chance to be paid upon initial submission.

In this post, we cover the top reasons we see leading to denials. We hope you will learn a little about why some claims deny and in part three, what can be done to get them paid. Why?  Because when claims are denied, the follow through is often incomplete and the claim can easily fall through the cracks and you never get paid.

Like most everything else we tell you about, your results are directly affected by your work up-front in pre-admissions. The more you know and have verified about your resident and their coverage(s), the fewer problems you will have.  Yes it sounds obvious, however this is the root cause of many of the claims we are asked to help get paid.


Here is a list of the types of denials that will make up the bulk of your unpaid claims.  The important and useful thing about denials is that you can learn from them.  Just because a claim is denied does not mean that it will never be paid. For those of you that have seen the movie Rainmaker, I sometimes wonder it isn’t true that an insurance company plays the odds and denies all claims to see who will file an appeal.

“Unclean claims”:

  • BOTTOM LINE-Clean claims pay faster because they are formatted exactly how the payer wants it.  It’s not hard to do. Invest the time.
  • You need to know your contract’s billing requirements.  Many successful billing offices have a binder with examples, or at least a cheat sheet to help anyone who is working on the billing.
  • Never assume that a Medicare Replacement claim is billed the same as a Medicare claim, even when it is supposed to be paid according to RUGs.  The requirements for everything from revenue codes and modifier codes to HCPS codes can vary widely between companies and plans.

“You need to bill someone else”:

  • There are many claims that are incorrectly submitted to the wrong payer.  You need to avoid this at all costs.  You need to know their coverage and who to bill from day one. This starts with a correct census, which starts with the pre admission process.
  • Many of these claims are the result of denials related to Medicare coverage.  Most facilities are used to checking the Medicare Common Working File (CWF) for Medicare admits, but we advise that it be checked for every admission.  There have been many instances where checking the CWF would have prevented significant problems. This can happen one of two ways.  Either someone is admitted as Medicare when the CWF would have shown active HMO coverage, or the other way around.
  • It is imperative that these coverage issues get caught and cleared up as soon as possible.  The different payers have different requirements for everything from authorizations to timely filing.

“Timely Filing”:

  • The first step in avoiding timely filing issues is simple; bill every claim monthly.  Here we go, stating the obvious again.  We have to say it because of how often it doesn’t happen.  Why does this happen?  It is simply because many facilities save the Managed Care claims for last, they know to get Medicare out but Managed Care takes a back seat.  This is especially true for facilities with just a few claims each month.
  • Timely filing requirements can vary as widely as just 60 days for some HMOs to 1 year for Medicare.  By billing every month, you give yourself a chance on every claim.
  • Although the timely filing rules vary,  the key to beating timely filing is to keep the claim alive through billing and follow-up work.
  • Make sure you document every electronic submission, mailing, phone call and letter in the billing/collections notes part of your billing software.
  • Make sure they receive your claim. If you keep getting told that the claims you resubmit have not been received, then take the initiative.  Fax them, send them registered mail, deliver them in person or whatever you need to do have them admit and verify they got your claim.
  • Unbelievably, we still see facilities that almost automatically write off a claim that has received a timely filing denial. There is no reason for this.  If the claim has been billed with regular follow-up and documentation, then the chances of beating a timely filing denial are good. And we recommend taking time to file an appeal before writing it off.

“No PreAuthorization”:

  • Collections begin at admissions.  We say it over, and over… because it is true.  You need to know at pre-admissions who you are admitting, what coverage they have and the admissions and billing requirements for that coverage.  Always verify if an authorization is needed or not.  Plans change and a company will require pre-authorization for some of its plans and not others.
  • Having a claim denied for lack of authorization does not have to be a write off. It is possible to get a retroactive authorization if you ask for it.  You may have to send medical records and a letter explaining why the authorization was not requested before admission.  It is possible, but it is a lot easier to get it right from the start.

“Reason of the month”:

  • I sometimes wish a phone rep would just say their company “just didn’t feel like paying” the claim.  That would at least feel like the truth.  It does seem that many companies are being more selective on which claims they do pay, and when.  The reason of the month can be anything from “inappropriate billing” to “Medicare primary”.  It doesn’t matter what their reason or code is, stay in contact, clarify what needs to change, resubmit it, verify they receive it and do it all over as often as needed to get paid.
  • Don’t be afraid to ask for a supervisor, manager or higher. Remember you are working on behalf of their customer/member, so be an advocate for the resident as well as yourself.

Stay tuned for  tips on how to respond to denials in our next post where we will be covering what you can do to get the denied claims paid.




services brochure

5 ways to increase your revenue without adding a single resident

Chances are that you’re leaving revenue on the table. This quick resource guide will help ensure that your office is getting the most from your existing business so you can maximize your revenue without adding a single resident.

    For more information, please call 407-977-8878 or contact us. One of our experts will answer all your questions.