Hard vs Soft Denial in Medical Billing: What’s the Difference?

Hard vs Soft Denial in Medical Billing: What’s the Difference?

Hard vs Soft Denial in Medical Billing: What’s the Difference?

When it comes the hard versus soft denials in medical billing, which is better? To find out everything that you need to know, click here!

Medical billing is often a higher stakes game than firms realize. Procedures can be expensive, and insurance companies know this. Part of their game is denying any claims they legally (or sometimes even illegally) can.

Navigating insurance is perhaps the most challenging part of medical billing. Insurance companies have numerous hoops and loopholes to hide behind when they don’t wish to pay. However, if a plan should cover treatment, you need to stay determined.

When a claim is denied, your company needs to start asking questions. Odds are your patient will have difficulty paying on their own. You need to know if there is an alternative.

This is when you need to determine if the claim was a hard denial or soft denial. The answer to that question will more or less guide you to your next best course of action.

Hard Denial

Hard denial is the worst form of denial an insurance company can send. It means they have reviewed the information given and decided the service is not covered.

For expensive treatment, this might destroy a patient’s life through debt. For a medical firm, it may mean they cannot get the pay that was ostensibly agreed upon. 

This can happen for a couple of reasons. While it may be an error, most common is that the prescribed treatment is simply not covered. Medical insurance rarely covers everything.

There’s no easy answer to hard denials, but things aren’t hopeless yet. The denial should be reviewed to see if it was made in error. If the denial doesn’t make sense given the insurance plan, coverage is still possible with the right steps.

What to Do If a Claim is Hard Denied

Getting a claim hard denied is more or less a worst-case scenario. Your options are limited, but they still are not zero.

The best thing to do if a claim was hard denied is to file an appeal. If the terms of an insurance plan cover the service, the odds are good appealing will work.

Generally speaking, a patient will be the one who files an appeal. However, a medical firm will be an essential component, too, as they must provide details as to why the procedure is necessary. 

Make sure the appeal is filed on time, as there will be a deadline to the process.

Unfortunately, if a procedure (or anything else) is not covered in terms of an insurance plan, appealing won’t work. It is challenging to get an insurance company to cover anything but what is required. 

For this reason, it is essential a medical firm check and see what a patient has covered before prescribing treatment. If an option isn’t covered, the best practice is first to see if there is an alternative that is equally medically viable that is covered.

Soft Denial

Then there is soft denial. Soft denial is when an insurance company reviews a claim, and there is some more minor issue. They occur when the insurance company needs more information before they can payout.

A soft denial does not mean the insurance company has no intention of paying. Instead, it means either a form was filled out incorrectly or they just need a doctor to confirm certain details.

Soft denied claims are usually called “rejected” rather than “denied” by insurers. This is just an easy way to differentiate between the two types of denials. A rejected claim is far preferable to a denied one.

These types of rejections are relatively common if a doctor is recommending a treatment that may be slightly unusual. This is especially true if the treatment is more expensive than a more common alternative.

Often the insurance company just wants to verify it is medically necessary, and there are no equally effective alternatives. 

What to Do If a Claim is Soft Denied

Unlike hard denials, you have more options when a claim is soft denied. The first thing that should happen is the patient, and their doctor should get into contact.

From there, they can discuss the details of the issue and work on solving it. Usually, it will be as simple as getting the correct info to the insurance company. Then the claim can go through as normal.

Remember to still go through this process with some urgency. There can even be deadlines for correcting the error, and there may be a lag between the different parties they may need to communicate. 

Consulting with our team at SAVI Group can help simplify processes like this. We are experts in streamlining the billing process to help both medical firms and their patients have the best experience possible. Medical billing and coding don’t have to be an uphill battle.

Experts like ours can reduce the number of denials you see by making sure everything is compliant, efficient, and resistant to error.

Don’t Let the Complexities of Medical Billing Claims Stop You

It is in the best interest of insurance companies to make medical billing a complicated process. The more difficult it is to make a successful claim, the less they have to payout. This is no more clear than when examining the denial process.

That all said, dealing with denials and rejections is not an unwinnable battle. If an insurance plan covers a treatment, then you should be able to get them to pay. It just takes time and the proper following of procedure.

If you’re interested in simplifying the medical billing process, consider contacting us! We’ve helped numerous doctors and their clients streamline the medical billing and coding process. We’d love to be able to help you too.