Can You Appeal A Denial When It's Not Your Fault?

Everyone hates hearing their biller say "it's not my fault", but sometimes it's true. There is nothing worse than calling an insurance to get benefit or claims information, only to find out months later that what was told to you is wrong. Now, you're knee-deep in denials with no way out. But, is there a way to appeal? There is no sure way to get claims paid once they were submitted incorrectly, but here are a few examples of denials I've seen, and how we got them paid:

Case #1: When telehealth first became the solution to Covid-19 treatment, insurances changed the way they wanted it billed frequently. A claim was billed to Tufts with the 95 modifier and 11 place of service. The denial reason stated it was not covered under the provider's contract. The biller called Tufts and the representative stated the CPT code was not covered. The biller disputed the reasoning since it was a PT evaluation code for a PT and the representative sent the claim back for reprocessing. The biller called to check on the reprocessing every 30 days and was told to allow more time. About 60 days after the initial reprocessing, the biller got a call from Tufts stating the DOS was paid. Again, the biller disputed this and it turns out the representative had sent the wrong DOS for reprocessing and will now send the correct DOS for review. The biller gets a call another 30 days later (now more than 90 days from the original denial) and the representative states the problem is they wanted a GT modifier and not a 95, and now it's too late to appeal. Fortunately, the biller had the dates and names of everyone with whom they spoken and what exactly was said. They sent in an appeal with a corrected claim indicating that had the correct DOS been sent for review on the first call, we would not have been over the filing limit. It took a little while, but eventually the claim was paid.

Case #2: A patient has UMR and is receiving treatment in the home setting via telehealth for several months and claims are paid timely. The patient decides telehealth is no longer necessary and allows the provider to come to the home for face to face services. A call is made to UMR to check benefits for this service and the biller is told there are 100 visits per calendar year for the service and no exclusions apply. The patient is seen several times and claims are submitted, only to be denied for medical necessity. A call to the insurance indicates they want the medical records faxed. The records are sent but we continue to get denials. It takes three calls to the insurance, and several representatives each call, to finally get the real answer- any services conducted in the patients home are considered home care and require a pre-authorization. Since the biller had all the documentation indicating when and with whom they spoke and what was said, they had sufficient proof, along with the medical records showing necessity, to obtain a retro-active prior authorization and get the claims paid.

If you have some patience and great documentation skills, it is possible to get paid when the insurance gives out misinformation. Of course, some insurances will not admit error or accept responsibility for giving out wrong information, so this is not fool-proof. However, one should always try.

If you have questions regarding your denials or how to appeal claims, regardless of whose error caused them, call or email us today.

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