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dure based on a vague "policy" or "guideline," consult with an attor-
ney.
Consider the patient's role in the process
Most of the time, patients are kept out of the claims process.
However, including your patients in the process is important in sever-
al respects.
First, if you're considering pursuing litigation for claims denial, be
sure that you've been in compliance with pursuing patient-shared obli-
gations. It is a provider's responsibility to bill and collect co-pays,
deductibles and co-insurance. While there are exceptions for financial
hardship, they are rare. A failure to engage in good faith efforts to col-
lect the patient's share can expose you to accusations of non-compli-
ance by the payer.
If a claim is rejected, consider balance billing — or charging
patients for the unpaid bill. While the laws vary from state to state,
many do permit out-of-network providers to balance bill a patient. In
the event a claim is denied or reimbursement has been significantly
lowered, balance billing can be considered as a way to increase rev-
enue. However, keep in mind that balance billing can negatively
impact your relationship with patients, as most don't look favorably
on the practice.
Get a lawyer involved
If you've documented everything, filed timely appeals and still
aren't getting anywhere, you may want to consider litigation. While
not practical for one-off denials, involving outside counsel may be the
right solution in several cases, including:
• Repeated denials. If payers are consistently denying payment on
high-volume, bread-and-butter work, it is worth it to evaluate the
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