Fight for insurance reimbursement rightfully earned


Understanding which insurance payment denials are valid and which are inappropriate is the first step to practices successfully getting paid for services rendered.

headshot of Suzanne Berman, MD

Suzanne Berman, MD

headshot of Angelo P. Giardino

Angelo P. Giardino

Pediatricians deserve to be paid appropriately for the services they deliver to patients. The process of documenting what care was delivered, using appropriate International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes to submit for billing, adding appropriate modifiers, and successfully transmitting this information through claims processing systems is ripe for problems that can lead to denials. Sometimes denials that are considered “improper” by practices are actually valid denials because the practice made an error or omission in the original claim submission. Other times the claim is inappropriately denied, and practices should be paid for the care delivered.

Understanding which insurance payment denials are valid and which are inappropriate is the first step to successfully getting paid for services rendered. When an inappropriate payment denial is identified, practices need to set up a plan to fight back to ensure compensation for money rightfully earned. This does not require all members of a practice team to be subject matter experts in this area, but a practice should have the collective knowledge to understand and advocate for the financial success of the practice.

In a session delivered on Saturday, October 26, at the American Academy of Pediatrics (AAP) 2019 National Conference and Exhibition in New Orleans, Louisiana, titled “David and Goliath: How to fight improperly denied insurance claims,” Suzanne Berman, MD, chair of the AAP Section on Administration and Practice Management, and Susan Kressly, MD, chair of the AAP Payer Advocacy Advisory Committee (PAAC), reviewed the billing concepts that all pediatric offices should be familiar with but often aren’t. These include an understanding of ICD specificity and mutually exclusive diagnoses, Medically Unlikely Edit (MUE) and Maximum Frequency per Day (MFD), as well as submission for Multiple Units. The presenters outlined the specific data elements that can often cause a claim to fail and may not even be visible to the pediatrician.

The presenters walked the audience through specific issues important for a practice’s revenue cycle-timely filing, knowing what claims are in which buckets, reviewing denials, submitting corrected claims, the appeals process, and triaging work.

Lastly, the presenters offered a step-by-step approach on how to take on “Goliath” and fight the payer for monies rightfully earned:

·      STEP 1: Understand the various reasons payers deny claims and what the electronic reason codes defined by the American National Standards Institute (ANSI) mean.

·      STEP 2: Contact the payer and ask why the claim was denied when the practice believes all the information was appropriately provided in the claim.

·      STEP 3: Appeal the payer decision.

·      STEP 4: Effectively advocate with the appropriate information to the appropriate body.

Kressly and Berman emphasized the need to understand the rules governed by the state insurance commissioner as well as state and federal Medicaid agencies to ensure that if an appeal is made it goes to the relevant authority for consideration. The presenters also discussed where pediatricians can go for assistance in both resources and leverage to address payment issues. For AAP members, some of the underutilized member benefits include:

·      The AAP coding hotline and various coding resources are available on the AAP website.

·      The AAP PAAC creates resources for pediatricians to help them receive appropriate payment from both private payers and Medicaid.

·      State chapter Pediatric Councils often have relationships with regional payers and can assist pediatric practices having difficulties getting paid.

“Pediatricians all deserve adequate payment for the services they deliver to the patients of their community,” said Kressly. “Understanding the rules, how to advocate for your practice, and where to look for resources and partners in this work ensures that we have the resources to provide high-quality care to the families of our communities.”


Understanding the processes that underpin billing and collections is an essential element to running a professional practice of any size. Large healthcare organizations typically have comparably large staffs to effectively manage the “revenue cycle,” which suggests just how important this element of practice management is to the functioning of the clinical. Smaller practices have an equal need to manage billing and collections but don’t typically have the resources to have an equally large staff focused just on this element of practice management.

Drs. Suzanne Berman and Susan Kressly offer a solution in their presentation “David and Goliath: How to fight improperly denied insurance claims”-namely, stay focused on a disciplined approach to the revenue cycle and make full use of the resources offered by organizations such as the AAP to keep up with changes in processes, learn tips for being efficient and effective, and to assist in prioritizing one’s time and effort.

The bottom-line message is that pediatric professionals practicing in all sizes of healthcare organizations can effectively manage their practice’s revenue cycle if they prioritize their efforts and make full use of the shared learnings and resources made available from their colleagues and professional organizations. Even though the payers are a much bigger Goliath than us, we have the benefit of shared experience and a desire to share best practices. This collectively gives us enormous strength to step up to this important task! Go David!


Angelo P. Giardino, MD, PhD, MPH, is Wilma T. Gibson Presidential Professor, chair, Department of Pediatrics, University of Utah School of Medicine, and chief medical officer, Intermountain Primary Children’s Hospital, Salt Lake City, Utah.

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