Step One: Review the EOMB. Not all denials are the source of insurance company flaws and greed. Check for a very basic technical errors. Is the CPT and ICD-9 codes correct for the service that you billed or is the problem simply a typo. Remember that computers base their decisions on coding and any transposition of numbers or letters will result in claim denial. Although many electronic claims are computer to computer connections there can still be some manual oversight which can result in claims denials.
On paper claims they're usually scanned through an optical scanner and this too can create technical errors. Always make sure the ink/print is dark and use block fonts which are very clear that computers cannot mistaken for other symbols and characters. Also check for the alignment of your information on the claim. Especially with the CMS 1500 form the information must be exactly in the designated boxes or the information will be misread.
Check to make sure all appropriate fields were completed. This especially applies to referring physician information. Leaving these fields blank may result in claims denials.
Many office computers are set with standard defaults. Most of the services we bill will be office based and computers are often set to default to place of service 11. But when billing outpatient procedures or even DME items the place of service must be corrected.
Lastly make sure that any modifiers that are used are used correctly. Using a modifier in an inappropriate condition such as using an evaluation and management modifier on a surgical procedure code may cause the claim to be denied on that basis alone. Learn when and how to use modifiers properly..
If you have eliminated all of the technical errors that could potentially causing claim to be denied the next step is to look towards medical necessity issues. Again read EOMB carefully as there is information listed as to the probable reason for denial. If it is not clear why the claim was denied you should contact the individual carrier and try to get additional information as to the denial reason. The EOMB denials can be vague so ask for clarification.
Once you have received the denial you can choose to either appeal the claim, resubmit the claim or unfortunately ignore the claim. Often times the dollar amount is minimal such that the time and effort to appeal a claim may not appear be worth the possible recoupment of money. However if the reason for the denial is not addressed that error will be repeated over and over again resulting in potentially lost revenue. Even if the denied amount may be but a handful of dollars, if this is a common procedure or supply utilized by your office this can add up over the course of a year. The goal of proper billing is to get paid for all of the services that you are legally entitled to. Not collecting or inappropriately billing on legitimate services is simply a revenue drain for your practice
Each carrier may have different rules regarding what claims can be appealed and which claims can be resubmitted. This is especially true of Medicare. Medicare claims will clearly state on the remark codes whether a claim can be appealed or simply resubmitted. The Medicare claim that has not been completely processed can be resubmitted. Errors in the claim can be corrected and simply submitted as a brand-new claim. This is because the original claim has never been offficialy recognized by the system and hence the subsequent claim will be processed as an initial claim.
If a claim is denied for medical necessity reasons than simply fixing the errors and resubmitting it may not be sufficient. Medicare will read such a claim as a duplicate and will deny it on that basis alone. You should submit the proper appeal form to the individual insurance carrier regarding your appeal. Services that can generally be appealed are services that were denied for medical necessity, services that were reduced or combined, inappropriate fee payments or if certain procedures were inadvertently omitted from the original submission.
It is very important to read the EOMB to try to determine the specific reason for the denial. Your appeal must address the underlying basis for the denial. Otherwise your appeal will be for not. When writing your appeal letter be very specific and be very professional. Ranting and raving and accusing the insurance company of being greedy or having inappropriate policies will not garner you any support when submitting your appeal. Clearly state why you believe the claim to be appealed should be paid. You must submit this based upon medical necessity not simply stating that this procedure was performed and therefore should be paid That is not reason enough to overturn a denial. For clarification you may ask the carrier for their written policy or the appropriate website to look up their policies. You may also ask what type of bundling software they use if your claim was bundled. If there are questions regarding fees you may ask for the carriers fee schedule. If your appeal is based upon an investigative or experimental procedure then you should submit supporting documentation or articles as well as possibly other insurance companies policies which do in fact allow this procedure. Also state why you think this patient may be entitled to a policy override if there are extenuating circumstances
Once a denial letter has been sent in it, there should be a process to track that letter. A person should be designated to follow up after a period of time (such as two weeks).
Once the problem has been identified (regardless of the outcome of the appeal) procedures should be put in place in your office to prevent this from happening again. Use this opportunity to train staff. If inappropriate claims information was placed in a claim or if information was omitted you need to train your staff as to what information is required. Many problems deal with modifiers especially as they pertain to routine foot care which is a rather complicated billing protocol. Further education would need to be given to your staff. This could include that certain ICD-9 codes are not appropriate for certain CPT codes.
If denials are based upon company policies then you need to be aware of your major insurance companies policies as to what services may or may not be covered. If x-rays, orthotics etc are not allowed in your office then send them out. Similarly if the amount of reimbursement is too low, refer those services out as well. You may drop some revenue but you will gain some piece of mind in the office by not having to hassle with certain items all of the time.
Lastly if claims continue to be denied or it is very difficult to work with the insurance company one option to consider is that you may not wish to continue to be a provider for that carrier. If you spend so much time fighting and appealing, the actual “net” to your office may be very little. Loosing that carrier may initially appear to be a loss but this may allow you to spend more time with other patients creating a better patient care environment and may actually build your practice even more.
