How to Handle Medical Billing Denials in NEMT 

Medical billing denials are a common and frustrating problem for NEMT providers nationwide.  

Denials typically happen when insurance companies reject claims for various reasons, such as incorrect coding, missing documentation, eligibility issues, or policy changes. Denials can result in lost revenue, increased administrative costs, and reduced patient satisfaction for NEMT providers.  

NEMT providers need a proactive and effective denial management strategy to help them reduce the number of denied claims, improve quality of care, and enhance customer experiences. 

This article provides practical tips and best practices for handling medical billing denials in NEMT, helping you recover the critical revenue you need to run a successful business.  

READ MORE: Why should fleet operators use NEMT software for billing and claims management? 

Review All Claim Details 

The first step in handling a denial is understanding why the claim was denied.  

Every denied claim should include an explanation specifying why it wasn’t accepted and what documents are required to resubmit or file an appeal.  

Depending on the nature of the claim, this could be a quick fix or another lengthy process. If you’re unsure whether the claim was denied or the denial doesn’t have clear instructions listed, you should contact the insurance company as soon as possible to clarify the situation. 

If a team member has the knowledge and capacity, assign someone the role of “denials specialist.” They can review each claim denial and work with the insurance companies to resolve them.  

It can be helpful to offer regular feedback and training to your staff and drivers on avoiding common errors and improving documentation. 

Be Persistent 

Handling claim denials is a complex task.  

Your resubmitted claim could once again be denied, but if you genuinely believe the denial was an error or you’ve corrected the problem but still aren’t seeing the right results, don’t give up.  

Familiarize yourself with the carrier’s appeal process and guidelines, and ensure you have all the information you need to succeed.  

When you submit your appeal, include an explanation of why you’re submitting it, any required documents per insurance guidelines, and copies of any prior communication you’ve had with the company. You may have to resubmit a claim multiple times before it’s approved, but it shows the insurance company that you’re serious about fixing the problem, and it will be well worth it when you get the money you’re owed. 

Address the Problem As Soon As Possible 

It’s easy to push your denials off when you first receive them, but this is one of the worst things you can do.  

Each claim has a firm deadline; the longer you wait, the less time you’ll have to gather all the information needed to resubmit. You risk losing your payment altogether if you don’t resubmit your claim by the deadline.  

Insurance companies are willing to talk when resubmissions are sent promptly, but they’re pretty unforgiving if you resubmit after the deadline. Keep a list of your deadlines where you can quickly view them to ensure you stay on track. 

Creating a denial resolution process that aims to resolve all denials within 30 days of receiving them can be a helpful way to ensure each denied claim is handled promptly and efficiently. 

Understand the Appeals Process 

Each insurance company’s appeals process will be different. 

Some may require more evidence, some may have more stringent criteria than others, and some may take longer.  

You need to know what steps are involved in each appeal process, how long they usually take, and what factors affect their outcome.  

You also need to know who handles each appeal, what resources are available for support, and what communication channels are preferred.  

By understanding the appeals process, you can prepare yourself better for each appeal, avoid unnecessary delays or errors, and increase your chances of success. 

For example, one of the largest insurance companies in America, UnitedHealthcare, has a three-level appeals process for NEMT claims.  

The first level is a reconsideration, which is a review of the claim by a person different from the one who made the original decision.  

The second level is a formal appeal, a review of the claim by a panel of experts not involved in the original decision.  

The third level is an external review of the claim by an independent third-party organization not affiliated with UnitedHealthcare. Each level has its own requirements, deadlines, and outcomes. 

Keep Records Throughout the Dispute Process 

One of the most important things you can do when dealing with denials is to keep track of everything related to each claim.  

This includes: 

• The date and time of receiving each denial letter or notification from the insurance company. 
• The reason code(s) assigned by the insurance company. 
• The explanation(s) provided by the insurance company. 
• Any documents attached by the insurance company. 
• The contact information of the person(s) involved in each appeal. 
• The status updates on each appeal. 
• The outcome(s) of each appeal. 
• Any feedback or suggestions received from the insurance company and any other relevant information that may help explain or resolve each issue. 

Keeping records throughout the dispute process will help: 

• Monitor your progress and performance on each claim. 
• Identify patterns or trends that may indicate systemic problems or opportunities for improvement. 
• Provide evidence and support for your arguments and decisions. 
• Avoid repeating the same mistakes or errors. 
• Maintain a professional and respectful relationship with the insurance company. 
• Comply with the legal and regulatory requirements. 

For example, one of the best practices for keeping records is to use denial management software that can help you store, organize, access, and analyze all your denial data in one place.  

Several denial management software solutions exist, such as Quadax, Experian, and Waystar. These programs can help you automate and simplify the denial management process, reduce manual work and errors, and increase the efficiency and accuracy of your denial resolution. 

Conclusion 

Medical billing denials are unfortunate for NEMT providers, but they don’t have to create problems.  

By following the tips and best practices we shared, you can confidently and efficiently handle medical billing denials in NEMT, adopting the best strategies and tools for you.  

Doing so can recover your lost revenue, improve your quality of care, enhance your member experience, and grow your business. 

Are you looking for comprehensive NEMT software that automatically applies service codes, streamlines accurate claim submissions, and reduces errors? 

Sign up for a free 30-day trial and experience how Tobi makes your business better at every turn.