Payer disputes are common in the healthcare industry. If you’re a patient, you will likely have to deal with them.
A payer dispute is when a patient disputes a bill with their insurance company. It might happen because you feel the charges are too high. Or they were charged for services that weren’t covered by the plan.
Therefore, it’s vital to resolve payer disputes quickly, as they can affect your customer experience scores and retention rates. Thankfully, this article will discuss how to resolve payer disputes in five steps.
1. You Need to Identify the Problem
The first step is figuring out what’s going on. Who is disputing the claim? What does the payer say about it?
However, this can be tricky because sometimes you don’t know if there’s an issue until you get a denial notice. For instance, you don’t know that your patient’s insurance plan doesn’t cover certain services until you submit the claim.
Most of the problems you might come across include the following:
● Denial of service. A denial of service is when the insurance company says they won’t cater for the service that has been provided. It occurs when there is no medical necessity or, in a case, you didn’t meet their deductible.
● Policy violation. It might occur in a scenario whereby you’re denied coverage or charged unreasonable fees because of a policy violation that isn’t your fault. For instance, in a case where your insurer requires pre-authorization for certain services and your doctor didn’t get one.
● Coverage dispute. This type of dispute occurs when there’s an appeal process for an insurance claim, and the insurer disagrees with how much should be paid for services rendered.
● Billing error. In case you think a bill is incorrect, don’t just ignore it. Contact the patient billing department of your health plan and let them know what happened. They will review your claim and determine if additional information is needed or adjust the records based on your information.
2. Review Your Contract
At this stage, review your contract to determine if there’s an issue with the payment. If so, it might be easy to solve.
For instance, in one case, the payer says that your medical service was not covered, and that’s why they’re disputing payment. Then, check your contract and ensure you’re providing the correct information about coverage.
3. File a Claim Rejection Appeal
Suppose you don’t find any information in your contracts about handling denial claims, then contact the payer directly. Ask them to review the claim again.
If they still deny your appeal, consider contacting their customer relations department in writing again. Consider requesting a formal written response explaining why they denied your appeal request.
In case they still decline payment after this second appeal, then consider finding another way to resolve the issue. It’s because, at this point, there’s nothing more.
4. Negotiate with the Payer
In this step, try to negotiate with your payer. You may resolve the issue by explaining why they shouldn’t have paid your claim.
For instance, suppose there was a mistake in the claim handling process, or if their rules were unclear, you could ask them to give you more information about why they believe your claim is invalid.
When you’re negotiating with a payer, there are some things to do to ensure that the negotiation goes well:
● Have an open mind.
● Be prepared to compromise.
● Be respectful and polite at all times, even when frustrated or angry.
● Ensure you understand why you’re having the dispute in the first place before talking about it with anyone else.
If you disagree with the reason for a denial, then consider filing an appeal.
5. Consult an Attorney
In the event you’re denied payment by a healthcare provider and you’re struggling to get them to pay up, you may be tempted to take matters into your own hands. Kindly don’t do it!
You should consult an attorney before taking any action. In that scenario, there might be a good reason for it. If you don’t know what the reason is, and in the event that you do, how will you tell whether it’s legitimate or not?
To avoid more issues down the road, consider contacting a local attorney specializing in medical malpractice cases. They’ll be able to evaluate your case and help determine if there’s enough evidence for a successful claim.
Hire Experts at PayrAdvisors for Your Payer Disputes
When you’re in the middle of a dispute with a payer, you can’t afford to wait. PayrAdvisors is a team of specialists who work to resolve payer disputes between customers and payers, contract management & negotiations, credentialing, and payer analytics, among others.
We have decades of experience in the industry and have helped hundreds of customers get paid faster. If you are dealing with such a dispute, we’ll be happy to answer all of your questions. Kindly set up an appointment with our specialist to get started.