One of the most common reasons for denied claims? Incomplete or incorrect details or documentation. This is an error you can't afford to make. "Your goal is to send in clean claims, with all the information where the payor wants it," says Mary Pat Whaley, FACMPE, administrator at Bariatric Specialists of North Carolina in Cary, N.C., and editor of the blog ManageMyPractice.com.

Often the problem lies at the payor's end. A carrier repeatedly denied the Endoscopy Center of Marin's facility fee claims based on the mistaken belief that they were being filed by a physicians' group, not a surgical facility. In that situation, "you just have to call them up and have them pull up your contract," says Laurie Masonheimer, CPC, a billing specialist for the Greenbrae, Calif., facility.

Be aware, too, that they might not let you know when they're waiting for additional information. "They don't pay a claim because they've sent the request to the patient," says Ms. Whaley. "If you don't know this, and the patient doesn't understand the request, there's a disconnect and a delay." Take note of the reasons for denials, and consider explaining to patients how the insurance process might involve them in advance of their surgeries.

Even if your claims are consistently clean and on time, you're still likely to see the occasional denial. "The way the insurance companies make money is through premiums and through not paying claims," says Karlene Dittrich, CBCS, a revenue recovery and appeals specialist for MedRevenue Solutions in Atlanta, Ga. "They find reasons to deny, which can be a delaying tactic to hold onto the money longer, but which sometimes goes to the point of questionably deceptive practices."

Perhaps the payor declines payment, rightly or wrongly, due to untimely filing, a lack of authorization or medical necessity, on grounds that the procedure was experimental or for no reason at all. Perhaps a change in their processing system, recent staff turnover or incorrectly recorded contract details caused the delay. Maybe they even report that they never received your claim.

In any case, it's a source of frustration to your business staff. It may burden them with duplicating earlier efforts and it gives the payor 30 to 45 more days before they have to pay you. And you won't know if this is a recurring trend unless you keep track of their stated reasons for denials. "You have to really sit on top of it," says Ms. Whaley. "If your payor mix has been constant, but suddenly your payments are coming in 2 weeks slower than they were, or you're seeing new denials that you hadn't seen before, you'll know when it's time to go talk with them about not paying according to contracts."

Know your contracts and your rights
Know your contracts and the state and federal laws that govern them so that you know what recourse you have in the event you've been underpaid, says Ms. Masonheimer. Any provision that isn't compliant with state or federal law is unenforceable, says Ms. Dittrich.

Load into your system the allowables and the specific procedures for billing implants, says Ms. Whaley. In addition, keep an eye out for any changes made to your fee schedule between renewals. "Your contract is 1 or 2 fee schedules and 60 pages of how not to pay those fee schedules," says Ms. Dittrich.

"Insurance companies take advantage of the fact that providers don't know the laws, and then they dictate dispute resolution," she says. "Be familiar with the laws that rule your contracts. That will level the playing field and hold the insurance company accountable."

Appeal ASAP, and be specific
Appealing denied claims is a time-consuming and often low-return activity, but it's best to avoid putting it off for too long. "Work your denials as soon as you can," says Ms. Masonheimer, especially if you've noticed a trend of denials from the payor at issue. "Be quick to send your appeals."

Not only are you under a contractually specified (and federal- or state-law governed) time limit to appeal denied claims, she says, but since the payor won't likely respond immediately, the sooner you file, the sooner you'll resolve the situation.

When you appeal, be specific in your disputes. "You have to say, this is a recurring problem, a trend," says Ms. Whaley. "This claim needs to be fixed, made whole, recompensated according to contract. Be specific or else the payor will say, 'It all looks good to us.'"

If necessary, demand an explanation of the denial process for a claim or even a review by an external mediator. This is where knowledge of the laws overseeing and rights guaranteed by the contract can come in handy.

"Payors tend to change their rules on a whim," says Ms. Dittrich. Whatever their reasons for denying a claim, appealing with supportive evidence is your best strategy for making sure they're paying your rate based on contracted charges (or, if you're out-of-network, based on their agreed-upon schedule of billed charges).

A lack of authorization, pre-certification or medical necessity are common reasons for denial, even after a payor gives the go-ahead for a procedure or implant. "Typically, there are departments for authorization and there are departments for claims processing," says Ms. Dittrich. "They don't always speak to each other." What's more, they may not offer to. But you have the right to request a full-and-fair review for medical necessity, and you don't have to provide extenuating circumstances to do so, she says.

Sometimes the reasons for denial aren't quite as cut-and-dry. Payors may decline to honor claims due to codes or modifiers that did not appear on the original bill, says Ms. Dittrich. They may cite ambiguous payment methodologies or maximum allowable amounts seemingly chosen at random (which has been the subject of many a class action lawsuit). They may argue that an unpaid claim was never received, or deny one with no explanation at all.

When all else fails, make them prove it. "As a provider, you have rights of disclosure. You can put the burden of proof on them," says Ms. Dittrich. "It helps to hold them accountable when you can ask on what basis they made a decision."

A working knowledge of the details of your insurers' plans, as well as state and federal insurance regulations and coding guidelines, is essential but difficult. "It's a lot of information. It's a bit overwhelming," says Ms. Dittrich. But the right training and resources can help you master the rules and navigate their changes. Some coding and billing software packages include templates that contain the proper language for filing appeals. CMS and the American Academy of Professional Coders hold CE conferences and webinars.

In-person interactions at conferences or with consultants can shed light on opportunities you may not have known were available. "In my training sessions, I've often told classes, 'According to the contract, you can do this,' and someone asks, 'We can do that?'" says Ms. Dittrich.

It may also be useful if your billers are current not just with CPT and ICD-10, but also with information technology, says Ms. Whaley. That way they can troubleshoot possible snags and situations that may be derailing claims between your facility and a clearinghouse or a payor.

Know your contacts
Make friends with the payors' representatives, says Ms. Whaley. "Invite them to your facility, call them up. Make connections inside who can give you the heads-up and explain things."

If you regularly communicate with your contacts at the insurers, it's easier to resolve disputes without suffering them over the long term. "A relationship with people at the payor will help you keep small things small," says Ms. Whaley. If a dispute turns into a continuing trend, however, keep regulators in the loop. Ms. Dittrich recommends copying the state insurance commissioner on exchanges you have with payors while trying to resolve long-running disputes.

"I'm not saying the insurance commissioner will solve a situation for you, and don't rely on them to take a personal interest in your case," she says. "But the more that you involve them, the more you notify them of patterns of errors and establish a trend, the more they'll pay attention."