Denied…what now?

We’ve all been there.

  • The insurance company will not credential me now what?
  • The needed prior authorization for [insert drug, imaging, lab test, etc here] was denied, now what?
  • The claim for a medically necessary visit was denied, now what?

One of the most frustrating things for healthcare providers (regardless of the initials after the names) is that we simply want to take care of our patients, but sometimes we cannot. Frustrations build when we cannot get the needed medication, supplies, services, testing, referrals and more for our patients…simply because the insurance company will not pay for it.

And our frustration grows when we spend the time and energy advocating for our patients, getting nowhere. That frustration can peak when we are also denied payment for our services.

Of course, these denials add up over time, potentially putting a patient at risk for further cost – financially, medically and otherwise; and they put the provider and practice at risk.

Hence, a common question is what should I do? How do I get beyond these barriers?

The insurance company will not credential

Many insurance companies put barriers up for Nurse Practitioners and will not credential them, or make it more difficult to get credentialed.

NPs have reported to me that insurance companies will tell them they do not credential NPs. And yet, other NPs are credentialed by them.

They will tell NPs they cannot be credentialed unless their collaborator is also credentialed. Even though the physician is not seeing the patient. And even though that NP is in a state that allows full practice authority (ie, no collaborating physician required).

If this happens to you, here are some steps you can take:

  • Go up the chain of command. Ask for and document the name of each person you speak with. Get direct phone numbers and even employee ID if necessary. Document the conversation and then continue up the chain. At all times clearly state what you want, what the laws currently are and offer documentation. Be respectful.
  • Contact AANP and the Multi-State Reimbursement Alliance who is also working on reimbursement issues.
  • Your patients are their customers. Have them call and write to their patient representative as well.
  • Consider contacting the insurance commissioner in your state.

Authorization Denial

We’ve all spend time on the phone trying to get an authorization. We’ve spent time gathering all the documentation, filled out forms online or print them, filled them out and faxed them in. And we’ve called back to follow up because we don’t get an answer. Not once, but multiple times.

In the following video, Kevin Pho of shares some of the strategies and results shared by physicians in his community. It boils down to three very familiar words….document, document, and document.

Payment Denial

You work hard. You deserve to be paid. It’s essential to the bottom line of your practice to be paid. Without revenue, practices cease to exists. Patients have less access to care. The community, especially smaller communities suffer when they lose a health care provider.

Without revenue, practices cease to exists. Patients have less access to care. And the community, especially smaller communities suffer when they lose a health care provider.

A big part of claim management is preventing denials to begin with. Being aware of the most common reasons for denials can help.

  • Coding is not specific enough.
  • The claim is missing information.
  • The claim is not filed on time.
  • Incorrect patient identifier information.
  • Coding issues (outdated codes, wrong codes).
  • Duplicate billing.
  • Upcoding or unbundling.
  • Further documentation requested to support medical necessity.
  • Referral or prior authorization required.
  • Service not covered, or coverage terminated.

By knowing the most common reasons claims are denied, your practice can ensure claims are submitted with the correct information. This will cut down on unnecessary denials. Prepare by collecting all the necessary information to be submitted to insurance and submit the claim at once, without delay.

But it you’ve done all you can to submit correct and complete information, yet the claim still gets denied, follow up and don’t give up. Have all the facts when you call and document, document, and yes, document.


Comments 2

  1. I have been unsuccessful in California getting credentialed and contracted with Blue Cross and Blue Shield. They instruct me to bill under the supervising physician’s name and number however my supervising physician is not on site and never sees the patient however they say that is just fine. But we all know that the NP should be billing under their own name and number therefore my patient’s are forced to pay a higher co-pay or the whole bill as I am out of network for them. Does anyone have any other thoughts or advice as to make this work??? Or is this the case for California for now?

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