Claim denied and some reason code
is given. Now you have to research what it means and what to do about it. In too many cases, office staff puts these
aside to work on later, and then that put aside, become pushed aside for other
priorities, and becomes denied for lack of timely appeal. Revenue loss.
Denials are very different from
rejections, and staff needs to be able to read an understand the Explanation of
Benefits (EOB) messages. Rejections are
errors in the data that was submitted, correct it, re-submit it and move
on. Practices should never let
rejections become denials because they are not fixed and resubmitted timely.
Denials are another matter
completely. Here the payer is saying no –
we won’t pay.
There are two basic reasons for
denial – failure of the patient to be eligible for the services you provided,
and failure of you to be authorized to provide the service that you
provided. These can only be fixed by an
appeal.
Read More: Are you looking to Switching EHR Vendors? CureMD will help you choose the best emr for your specialty-specific or muti specialty practice
Denials for lack of patient
eligibility means that the health plan is saying, not my responsibility. The
problem is that you do not know what the plan is relying on when they say
that because you only relied on the information that the patient gave you at time
of service. And here is the rub. You may have even verified eligibility at the time of service, but low and behold, now they are saying that the patient was
not eligible. This is a fight you can’t
win, and appealing will only result in further denials.
This is a problem you have to
make the patients. Bill them, pass on a
copy of the denial and let them fight with their insurance company. Hold them responsible, and if you have
planned for such an event, you have taken a contingent credit card authorization
to bill the card just for this type of possibility. Bill the card, and your done. Now if the insurance company relents based on
the patient arguing with them, and you do get paid, promptly issue a credit to
their card. And be sure to keep the patient
in the loop; advise them of the denial and the credit card billing and if paid,
advise them of the credit being issued.
Denials for lack of authorization
run the gambit of the lack of a referral for the procedure, to a requirement
that you are “accredited” or certified” to provide a certain procedure or
service.
Your office should build a matrix
of all the plans that you participate with, and which of those plans, or
products of those plans require pre-authorizations, referrals, or
accreditations/certifications. And if you are adding a new service, especially
a piece of technology, don’t believe the salesman that tells you that you will
get paid by everyone for using it. Make
sure you verify with the health plans directly. (Or better yet, make the
salesman guarantee his words with consequences)
If you are a specialist then
there is a likelihood that at least some of your pay sources will require prior
authorizations or referrals. Best to
know beforehand. And never let the
patient dismiss your request for a referral with the promise that they will get
it later. Get it before services are
rendered. Two ways (1) invite them to
all their primary care physicians and ask that it be immediately faxed, and (2)
invite them to sign a waiver that if they do not get the referral, or it is
invalid, or if they claim it is not needed, they will take personal financial
responsibility and pay the bill, in full.
And get that contingent credit card.
If your practice includes
ancillary technology, such as imaging services, be sure to verify that if you
provide them to your patients they will be covered by the payers. Imaging services, in particular, are
increasingly coming under the egis of specifically contracted subnetworks, and
if allowed by practitioners, only if they are “accredited or certified” to
provide.
