DISCOVERING THE DIFFERENCE BETWEEN HARD AND SOFT DENIALS (2024)

Medical billing can be challenging, as insurance companies often deny claims they legally or illegally can. The most difficult part of medical billing is navigating insurance, as there are many hoops and loopholes to hide behind when insurance companies wish to avoid paying. If a plan should cover treatment, it's important to stay determined. When a claim is denied, it's important to start asking questions to determine whether it was a hard or soft denial. Knowing the answer to this question will guide the next course of action.

WHAT IS A HARD DENIAL

Receiving a hard denial from your insurance company can be a real gut punch. It means they've looked hard at your case and decided that your plan doesn't cover the treatment you need. And let's face it, that can be a crushing blow - especially if the treatment is expensive. It's not just patients who feel the sting of a hard denial either. Providers are often left high and dry, unable to collect the payment they were counting on. The most common reason for a hard denial is that the treatment falls outside the scope of the insurance plan. But before you give up hope, it's essential to scrutinize the denial to see if there's been a mistake. If the denial doesn't match up with your plan, there's still a chance that you could be covered - you need to take the proper steps.

ADDRESSING A HARD DENIAL

If your insurance claim is denied, taking the necessary steps to file an appeal is essential. One of the most vital factors is whether your insurance plan covers the service in question. If it is, then there is a high likelihood that your appeal will be successful. However, it is essential to note that patients are responsible for filing the appeal. Still, seeking input from the medical firm providing the service is equally important. This is because they can provide crucial details necessary for the appeal process.

Submitting the appeal within the specified deadline is essential, as failing to do so may lead to its rejection, even if it has valid grounds.

On the other hand, if your insurance plan does not cover the service in question, then filing an appeal is unlikely to be successful. Insurance companies usually only protect services that are deemed necessary, so medical firms need to check what is covered by the insurance plan before prescribing any treatment. If an alternative service is available that is equally viable and covered by the insurance plan, then it is advisable to consider that option instead. Doing so can save you the time and effort of filing an appeal that is unlikely to be successful in the first place.

WHAT IS A SOFT DENIAL

Insurance claims are not uncommon to be denied by the insurance company, but it's essential to understand the two types of denials that may occur. The first type is a soft denial, typically when the insurance company requires additional information before approving the claim. Soft denials do not necessarily mean that the insurance company has no intention of paying out on the claim. Often, it's due to a simple mistake, such as an error in the form or a request for further confirmation from a medical professional. In such cases, insurance companies generally refer to these claims as "rejected" rather than "denied," distinguishing between the two types of denials.

A rejected claim is a better outcome than a denied one. Rejected claims are common when a healthcare provider recommends a treatment that may be slightly unconventional or more expensive than a more commonly used alternative. In such situations, insurance companies usually want to verify that the recommended treatment is medically necessary and that no equally effective options are available. It's important to note that soft denials and rejected claims are not the same as hard denial, which occurs when the insurance company thoroughly reviews the claim and ultimately decides not to cover it.

ADDRESSING A SOFT DENIAL

In a softly denied insurance claim, the patient and their doctor must work together to address the issue. This involves a thorough examination of the details to find a resolution. The insurance company may be able to provide the necessary information, but it's crucial to act quickly as there may be a deadline for fixing the mistake. Ineffective communication between the various parties involved can further complicate the resolution process. Therefore, it's essential to have prompt and efficient communication to resolve a soft denial claim successfully.

YOUR ANSWER TO DENIAL RESOLUTION

Insurance companies have a vested interest in making medical billing a complicated process. This is because the more difficult it is for a claim to be successful, the less they must pay out. This is particularly evident in the denial process. However, it is essential to remember that dealing with denials and rejections is not an impossible task. If an insurance plan covers a treatment, you should be able to get them to pay. It just requires some time and following proper procedures. If you want to simplify the medical billing process, it may be worth reaching out to experts like Bottom Line RCM. Get started today by scheduling a complimentary revenue cycle assessment! Contact us at (518) 837-7901 or email us at mstdennis@bottomlinercm.com. We're eagerly anticipating your response!

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Bottom Line RCM, LLC.

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