Handle denials due to coverage issues

Simply having coverage on the date of service is not enough. Your eligibility team needs to find out whether the service is covered by the patient’s benefits as well.

Categorized as Operations Tagged

For recalled patients, you already know the procedure that your provider wants to perform (vs a new patient appointment). This is clearly mentioned in the visit note and when your front desk made the appointment, they chose this visit type as well.

This tells your eligibility team that they need to ensure that not only is the patient covered on the date of service, but that the procedure/ service requested by the provider is also covered by the patient’s plan.

In other words, simply having coverage on the date of service is not enough. Your eligibility team needs to find out whether the service is covered by the patient’s benefits as well.

When you find out that there are coverage related issues, you need to do the same as before – put them in an “appointments at risk” bucket.

Your frontdesk or scheduling team should call these patients before the appointment and apprise the patient of their options. The patient can either cancel the appointment, reschedule the appointment until the insurance issues are resolved or they can choose to pay from their own pockets.

The workflow you are using here (or modifying) is that the billing department analyzes the denials, forms buckets, then trains / informs the front desk to make corrections upstream. This strategy allows you to reduce such denials moving forward.