Denials can wreck your revenue stream, but physician practices often give up on payment too soon, says Richard J. Quadrino, JD, founding partner with the law firm of Quadrino Schwartz in New York City. Many of your "dead" claims are payable if you know the law, he says.
"Providers often have a lot of denials that they've written off, figuring that they don't have value," Quadrino says. "Especially with smaller providers, we sometimes see a whole group of claims that were only partially paid and should have been fully paid. These providers have a lot more leverage than they realize."
Much of that leverage comes from the EmployeeRetirement Income Security Act of 1974 (ERISA), which, among other things, requires that an ERISA retirement plan be reimbursed for medical care provided to a beneficiary. Payers are under obligation to comply with a number of deadlines under federal regulations, Quadrino explains, and if they fail to comply with the deadlines, that gives the provider the opportunity to obtain full payment for the claim. (See the story on p. 3 for more information on ERISA requirements.)
Consider an example in which the payer does not respond within the required 30 days, instead waiting until 60 days have passed to say the care was not medically necessary or that more information is needed.