When Insurance Compaies Downcode

Purpose of the general appeals process

When insurance companies downcoded, reduced, or denied, a claim, providers and patients have the right to appeal the payer’s decision. The claimant or appellant can be the provider or the patient either one can starts the general appeals process for challenging the payer’s decision. These appeals must be filed by a certain time frame once the claim has been denied. In pursuing appeals the claimant must follow each payer’s procedures; most payers have structured steps for the appeals process. Claimants would start with a complaint, than an appeal followed by a grievance. Should the appeal be rejected the claimant is still not satisfied they can appeal to an outside authority, like a state insurance commission.

Claims that are rejected for missing a signature can be corrected by re-submitting the claim form with the correct information including the missing signature for the claim to be paid correctly.

Procedures that are not paid because they were overlooked one example would be a patient office visit

Partially paid, denied, or downcoded claims

Billing errors can also be reasons for claim denials or reductions. For example, should a patient visit the physician for an office visit but the insurance company receives a bill for a consult, the provider would receive payment just for the consult and not the office visit. If a patient visits a specialist but did not receive the required authorization prior to the visit, the claim may be denied, resulting in the provider’s need to appeal the claim (Jacob, 2001). Healthcare employees who handle billing and claims must be certain that all of the information they have for each patient is correct and up-to-date, and that they receive all necessary authorizations prior to performing any procedures. Additionally, insurance clerks have to be certain that they are using the proper...