Pay attention to contract to avoid denied claims

Appeal, even if a rule is broken

There are several things that access managers can do to help enhance billing efficiency and reduce the risk of claim denials, says Linda Fotheringill, a partner in the Towson, MD-based law firm of Siegel & Fotheringill, which specializes in helping hospitals turn around "hopeless" denials.

Here are Fotheringill’s suggestions:

  • Know the rules for each payer with regard to billing and appeal requirements.

If the payer contract indicates that the hospital will abide by all policies and procedures of the payer, find out what these are. If the contract incorporates the "provider manual" by reference, get a copy of the provider manual. It is her experience, Fotheringill notes, that many hospitals don’t even know where that manual is, much less are prepared to follow it.

For future contracts, insist on attaching the applicable policies and procedures to the contract. State that the hospital will not accept any changes unless they are agreed upon separately in writing by a designated hospital representative.

"Many hospitals have signed contracts that virtually give the payer carte blanche, and are operating under terms they’re not even aware of," she points out.

  • Identify and appeal all nonpayments, denials, and underpayments, even if the hospital has made a technical error, such as not getting preauthorization or failing to bill in a timely manner.

"If a rule has been broken and you’re not getting payment," Fotheringill says, "under contract law, there still could be a remedy whereby the hospital could get paid for valuable services."