unitedhealthcare: What to do about most common denials
Claim denials are frustrating and expensive to medical practices. The best way to avoid this frustration is to establish a process to significantly reduce the number of claim denials you receive in your office. See below for some tips on how to resolve some of the more common problems resulting in denials.
The most frequent claim denials at UHC, according to Dr. Gajdowski, are:
1. Patient is Not Eligible - A fundamental strategy in revenue management is to know where payment is coming from before you provide the service. In other words, is the patient going to pay or will an insurance company, and if so, which one?
If a patient presents you with a UHC insurance card, it is critical to check with UHC to see if that patient is a member of UHC. The easiest and fastest way to check a UHC patient's eligibility is to use UHC's Web site. Click here for UHC: Checking Eligibility and Benefits page.
2. Patient Does Not Have Benefit
Once you check eligibility, you are only halfway to determining whether UHC will pay you for your service. The next step is to determine if the service you are about to provide is a covered benefit for the patient. Remember, a benefits determination can't be made with finality until the doctor sees the patient and assesses the patient's needs.
When the doctor or other provider knows what service the patient needs, then it's important to check whether that service is a covered benefit for that UHC patient. This goes back to the fundamental rule of knowing who is responsible for paying. Sometimes practices want to engage UHC in a discussion as to whether the service being provided is medically necessary. The problem is that it may be a medically necessary procedure, but if the insurance policy states that it's not a covered benefit then the payment becomes the patient's responsibility. That means it's time to have a conversation with the patient as to how he/she is going to pay for the service. The easiest and fastest way to check whether a patient has a covered benefit is either use Availity.com or to use UHC's Web site. Click here for UHC: Checking Eligibility and Benefits page.
3. Notification
UHC has implemented a notification program that operates similar to a preauthorization process. Many members have expressed dissatisfaction with the notification process. The OSMA has strongly recommended that if UHC is to use a notification process then it should at least coordinate with patient eligibility and benefit availability so that physician offices can reasonably expect payment for a notified procedure. For the time being, if you want to get paid for certain procedures, you have to use UHC's notification procedures.
- In order comply with Notification as efficiently as possible, follow these directions:
- Become familiar with what procedures require notification.
- For more information and a list of the 2011 procedures that require notification click here.
- Submit notification online, when possible. To access notifications online click here.
Make sure you have the following information before submitting notification:
- Customer/enrollee name and customer/enrollee ID
- Ordering physician or healthcare professional's name and TIN or NPI
- Rendering physician or healthcare professional's name and TIN or NPI
- ICD-9-CM diagnosis code for primary diagnosis
- Anticipated date/s of service
- Type of service (procedure code/s) and volume of service (when applicable)
- Facility name and TIN or NPI where service will be performed (when applicable)
Notification is required at least five business days prior to the planned service date (unless otherwise specified within the Notification List). Note that notification for home health services is required within 48 hours after the physician's order.
If services are planned less than five business days prior to the service date, notification is required as soon as the service is scheduled. Remember: Physicians who have received the UnitedHealth Premium® quality and efficiency of care designation are exempt from the Advance Notification requirement for certain services as indicated on the Advance notification List.
Are you experiencing a certain type of denial frequently? The OSMA would like to know. E-mail us at info@osma.org or call (800) 766-6762. Let's take a look at each type of denial and how it could have been avoided.