Managing Denials and Appeals in Urgent Care Billing

Urgent care centers depend on reimbursement from patients' insurers to streamline their revenue. When urgent care administrative staff submits clean claims with all elements accurately documented, insurance companies accept the claim and send the payment, and if any submitted claim does not meet the guidelines of billing and coding, the claim gets denied; it has been noticed that over the past few years, claim denial rate has been increased rapidly by up to 20% or more leading to harmful effects on finances as well as the reputation of that U.C. facility. Managing claim denials and appeals is the key to booming revenue because effectively managing denials leads to betterment in recovery amounts, timely payment, increase in cash flow, improvement in reputation, and increased patient trust.
Managing these denied claims to re-appeal without exceeding the time limit is quite a daunting task, requiring urgent care providers or administrative staff to put extra effort, time, expertise, skills, and professionalism. The claim denial management process is not a piece of cake for everyone because your claim might get rejected more than once if you cannot find out the root cause of denial or are unable to rectify the issue; thus, handling this task to an experienced partner is a well-accepted approach to mitigate the hurdles managing denial and appeals in urgent care billing in the USA.

Mastering management of denials and appeals in urgent care billing: Understanding the process and strategies for effective denial management

When a claim is denied by insurers such as Medicare, Medicaid, commercial health insurance companies, and other 3rd party payers using denial codes, it is necessary to manage this claim professionally by implementing a denial management process to get reimbursement. According to research, you can prevent 85% of claim denial using good leadership qualities and competent skills.

Claim denial management process

In actuality, the claim denial management process in urgent care consists of detecting the reason for claim rejection (error) in claims, reviewing the denial code, solving this issue, and then resubmitting it to the insurance companies. Two types of claim denials use slightly different processes for management. Hard denials mean strict refusal of the payer to pay the reimbursement; therefore, it requires providers to go through a formal appeal process. however, soft denials mean you can revisit the claim, correct the issue, and then resubmit the claim.

Strategies for effective denial appeals

According to the Journal of AHIMA, unresolved claim denials put urgent care organizations under several negative, challenging situations, such as lagging patient volume, rising costs, wage inflation, as well as revenue loss of $5 million annually for those facilities (hospitals) having an average of 5% of net patient revenue; with up to 60% of denied claim are never resubmitted. AAPC has an extraordinary tool, i.e., a Denied claims calculator, to measure the cost of denied claims; however, around two-thirds of denied claims are recoverable with skills and experience. For this purpose, urgent care facilities seek a revolutionary first line of action to manage claims denials effectively for better urgent care RCM.

Find the root cause

The payers share Electronic Remittance Advice (ERA) and Explanation of Benefits (EOB) to tell you information about your submitted claim; EOB also provides information on whether the claim was fully paid, denied, partially paid, or delayed. In contrast, ERA tells the reason for denial using denial codes. Denial codes are alphanumeric codes used by insurers to explain why they have denied the claim.
Denial codes divided into four categories will show the reason, for example;

Denial code categories
Contractual obligations (CO)	CO-4 will be used to show the absence or incorrect use of the modifier. CO-11 shows some errors in coding, such as wrong diagnosis code or missing a typo in code, etc. CO-15 means that the authorization number is invalid or incomplete CO-18 indicates duplicate claims. CO-16 indicates inappropriate or missing patient information or wrong procedure codes, i.e., lack of information necessary for adjudication. CO-22 shows that another payer will cover the service depending on the coordination of benefits. CO-27 will be used when the cost is incurred when the patient's insurance policy expires. CO-29 will show that you have exceeded the time limit for claim filing CO-45 is the indication that the cost exceeded the contracted amount CO-167 means the diagnosis is not covered.
Payer-initiated reductions (PI) (Used when adjustment is not the patient's responsibility, but there is no contract between payer & provider)	PI-204 will show that the patient's current benefit plan does not cover rendered service
Patient responsibility (PR) (Used when adjustment represents a cost that the secondary insurer should pay)	PR-1 indicates the bill must be shared with secondary insurers because deductibles are not met
Other adjustments (OA) (used when no other group code can be applied to the adjustment)

Therefore, it is advised to read EOB and ERA if you receive them to get assistance in detecting the root cause of the denied claim.
To solve the issues, you should pay heed to the tips below.

1. Check the patient's insurance coverage termination date by contacting the insurers or reviewing the insurance policy.
2. Check Local Coverage Determinations (LCD) policies mentioned on payers’ websites to be sure about medical necessity.
3. Keep detailed and accurate information about all the steps taken involving date, time, and other records.
4. Know policy exclusions to understand any specific limitations & exclusions.

Perform the appealing process wisely

Appealing for denied claim procedure and guidelines may vary from payer to payer and state to state, but the paramount concern is "What must your appeal contain?" Your appeals are required to involve the following:

1. An explanation of your reconsideration request must be a formal cover letter that will justify the payer's reason for re-appealing and how your documentation supports these reasons for reappeal.
2. Supporting documents must include lab tests, progress notes, preauthorization & coding documentation, and other formal documents that can help justify your claim appeal.
3. Copy of denied claim with all relevant details and copy of initial claim submission.
4. Demonstrate medical necessity by providing additional information, such as a physician's letter.

Levels of appeal:
AAPC says that the Social Security Act presents five levels of appeals with Medicare, and for each level of appeal, Medicare has different CMS forms.
1st level: This initial appeal is also called internal appeal because it happens within insurance companies, and you request the insurer (Medicare contractor) to reconsider the claim.
2nd level: This secondary appeal level is more intense and must be done when the initial appeal does not bring positive outcomes. CMS says that at this level, insurers send a claim to a specialist, and reconsideration is done by a qualified independent contractor (QIC), a copy of RA or MRN and other formal relevant documentation must be submitted for this level of appeal.
3rd level: In this level, an Administrative Law Judge (ALJ) hearing is usually done by telephone or teleconference, and judgment is passed within 90 days of the hearing.
4th level: This level of appeal is called Review by the appeal council and can be requested in written form within 60 days of ALJ judgment.
5th level: It is called Judicial review, in which the U.S. district court passes the decision.

Staff education

Training & education are integral parts of modern healthcare systems to improve quality, and staff training creates skilled & confident staff and yields effectiveness. It is evidenced that after training, the percentage of clean claims reached approximately 75% to over 90%. Urgent care organizations must develop professional development interventions and training to support competent claim denial management workflow because it aims to improve the capabilities of the team and organization. The interventions that boost competence include formal education & training and information training strategies. Research suggests some strategies for education, such as group in-service training (on-the-job training), group pre-service training (training before beginning the task), peer-to-peer training, educational outreach visits, accreditation systems, printed information, and evidence-based practice (EBP). You must train your coders & billers in various coding disciplines to help them stay updated by obtaining continuing education credits (CECs) and minimizing the need to recruit new staff members.

Denial management software

Denial management software assists in maximizing performance by verifying benefits eligibility, pointing out all denials that can be readjusted, monitoring claim management in real-time, importing ERNs, preventing missed deadlines, emailing reports to specified personnel automatically, auditing the quality of redetermination and appeals and resolving denials hence saving time and ensuring efficiency & accuracy. Some other important aspects of this tool include claim scrubbing, denial tracking, analytics and reporting, automated appeal process, integration with other systems such as EHR & Practice management software, predictive analysis, and machine learning.

Conduct audits

Auditing is a vital key in managing denied claims and meeting the demand for quality improvement (QI) because they are conducted to assess quality and accuracy. Claim denial management audits in urgent care must conduct an auditing process for remittance advice reviews, zero payment claims, insurance verification quality, and write-off adjustment using both prospective and retrospective audits.
Prospective audits focus on current claims that have not yet been submitted or resubmitted to identify the errors and create clean claims.
Retrospective audits focus on claims that have been submitted (paid, denied, or delayed) with the aim of finding the bottlenecks of the submitted claims.

Stay on time

It is a wise decision to act quickly to correct your denied claim, preferably within a week, however there is a typical time limit of 30 days for the resubmission of the claim. There might be cases when you have ten days to submit, and in some cases, you may have up to 180 days based on the type of your insurance plan. When checking the time for appeal of a denied claim, it is advised to use the date mentioned on the denial letter or EOB instead of the date of receiving the letter or the date of service. Exceeding the time limit and being unable to justify being late will lead to no payment and distorted RCM.

Collaborate with payers

When you put all the effort into finding out the exact reason for the denial but are all in vain, it is high time for you to contact the insurers and request an explanation. According to the Patient Advocate Foundation, you must note down the time, date, and name of the representative you talked to, along with the summary of the call & information they provided you, and stay respectful in every possible way. Engage in payer-provider committees in order to exchange the best tips for managing claim denial, or you can share your data or record with the payers to detect the areas that can lead to denials. Along with direct contact with payers, you can also execute joint training sessions with them to understand and update the coding and billing guidelines set by payers.

Measure denial management performance

Tracking and measuring your management outcomes using urgent care KPIs entails identifying the areas that still need improvement and finding out how your current strategies are leading to success. Some of the urgent care key performance indicators for tracking denial management performance are given below:

Denial rate (percentage of denied claims)

Appeal success rate

Time to resolution (Meeting payer appeal deadlines)

First-pass denial rate

Appeal overturn rate

Outsource denial management to a servicer

There are several challenges faced by urgent care providers demanding to get assistance for better revenue. Some of these complexities include:

• Varying payers' rules and guidelines highly influence the denial rate.
• 31% of the providers still manage denied claims manually, delaying the challenging time.
• Denials reoccur because accuracy is demanded from 1st to last, and providers are prone to errors in any step.
• Managing and appealing denial often eats away your extra time because you might have to go through tens of thousands of phone calls, hence sparing less time for providing treatment.

Outsourced denial management services offer specialized denial management and appeals teams that perform skilled functions such as detecting root causes, end-to-end denial appeals and management, workflow optimization, staff training, and cost-effectively reducing in-house workload.

Outsourcing your claim denial management and appealing process to MedsIT Nexus is a valuable approach

MedsIT is a certified urgent care billing and coding company equipped with up-to-date technology and infrastructure that follows best practices to maximize your revenue cost-effectively. With more than a decade of experience, we understand how to identify the issues in claims to pinpoint the main loophole and then submit the appeal on a timely basis. Our denials and appeals management services will enable you to advocate our certified staff with insurers on your behalf to facilitate a successful appeal. Contact us today, as we believe in quality, not quantity. Our dedicated team is 24/7 is therefore for you.