Denials Management – Causes of denials and solution in medical billing

Denials Management in Healthcare – Medical Billing:

For proper denials management of medical claims in medical billing, first we need to understand the root causes of the denials in medical billing.

The causes of the denials are mainly because of the following 7 categories:

  1. Submitting the medical claim with an Incorrect/ Invalid Patient Information.
  2. Submitting the medical claim with an Incorrect/ Invalid Provider Information.
  3. Submitting the medical claim with an Incorrect/ Invalid Claim Information.
  4. Patient Insurance policy directives
  5. Human Errors
  6. Service related Complications
  7. Payment Complications

Now let us see the list of denials we come cross under the above categories in medical billing.

  1. Incorrect / Invalid Patient Information – Denials Management in Medical Billing:

Scenario 1: Claim denied as Patient cannot be identified as our insured (Patient Name/DOB/Gender/Insurance ID incorrect) – CO31 Denial Code

Scenario 2: Claim denied as Worker Comp/Auto accident related (This is work related injury/illness and thus the liability of the Worker’s Compensation Carrier) – CO19 Denial Code

2) Incorrect/Invalid provider information – Denials Management in Medical Billing:

Scenario 1: Claim denied as Provider not enrolled/Credentialed or Need W9 form to process the claim

  • A very first step is to review the provider credentialing list to understand the credentialing status (Dates of credentialing to see if the DOS falls within the time period).
  • If the date of service falls within the time period of credentialing, call the insurance company and reprocess the claim (Note: Mail the W9 form, if the insurance requests).
  • If the provider not credentialed, then medical claims need to be kept on hold until the provider is credentialed.

Scenario 2: Claim denied as Referring physician not available.

  • Review all the date of service of that patient to identify the referring physician name, if available append the referring physician name and resubmit the claim as corrected claim in block number 19.
  • If there is no information available, claim pertaining to the patient with same diagnosis code needs to be kept on hold and escalate to client.

Scenario 3: Claim denied as Provider not eligible to perform the service:

  • Review all claims for this provider with same CPT and DX combinations to see if any were paid.
  • If they are paid, then call the insurance company and reprocess the claim.
  • If there is no information available, place all the claims for the provider with same CPT and DX combination on hold and escalate to client.

Scenario 4: Claim denied as Provider ID incorrect or provider not part of the group:

  • Review all claims for this provider to see the claims billed with same NPI were paid.
  • Review provider list to ascertain the correct NPI#
  • If any of the information available, append the claim with correct NPI ID and resubmit the corrected claim.
  • If the information submitted already is correct, place the call to the insurance to reprocess all the denial claims (Note: If requested by the representatives, submit W9 form).
  • If there is not information available, then place all the claims for the provider on hold and escalate to client for further action.

 

3) Incorrect/Invalid Claim information – Denials Management in Medical Billing:

Scenario1: Claim denied as Invalid/Incorrect/No Authorization – Review the denial Code CO 15

4) Patient Insurance policy directives – Denials Management in Medical Billing:

Scenario 1: Claim denied as Patient not Eligible/No coverage on DOS.

  • Review other claims within a span of 30 days to see if any claims were paid.
  • Did we receive payment from the same insurance?
  • Is the paid claim has same insurance ID and check eligibility to confirm the patient was eligible at the time of service? If any of the above condition is satisfied, call the insurance company and have the claim reprocessed.
  • Check was there other insurance involved and paid claim for the patient within 30 days span. If yes, submit the claim to the valid insurance.
  • Review notes for any updation of new policy details.
  • Review path for any scanned copies of insurance information.
  • Check for accuracy of subscriber/ dependent information.
  • Check if patient’s age is less than 30 days, if yes, call the insurance and send the claim for reprocessing under mother baby clause. If not, bill the patient for valid insurance details.
  • If any of the information is available, make relevant corrections to the claim and resubmit the claim as corrected claim.
  • If not, please place a request for the patient to be contacted.

Scenario 2: Claim denied as Non Covered Service:

  • Review other claims to see if any claims were paid for same CPT/DX combination. If yes, call the insurance and have the claim reprocessed.
  • Check were there other insurance involved for the paid claims for the same CPT/DX combination. If yes, submit the claim to the valid insurance.
  • If denial pertains to Payer’s LCD, send it to coding review.
  • Review path for any medical records received to support the claim. If found, determine if an appeal has to be created.
  • Check previous notes to see if any appeal is already made. If so check if appeal has been denied, if not contact insurance and follow up on the appeal.

Scenario 3: Claim denied as Maximum Benefits Met/ Benefits Met/ Exhausted – Review Denial Code CO 119

Scenario 4: Claim denied as need Additional information from the patient (COB/Accident Info/Student Info) – Denial Code 17

Scenario 5: Claim denied as No out of network benefits:

  • Review other DOS for the same provider to ascertain if any claims were paid by the same insurance. If yes, call the insurance and have the claim reprocessed.
  • If the other DOS is paid in error, wait for the insurance to process the claim correctly and recoup the incorrect payment.
  • If previous notes correspondence/ denial states it is because of patient policy, transfer the balance to patient (Before you do, check client specifications).

Scenario 6: Claim denied as Global to the major service.

  • Review all the DOS for the patient to ascertain when the major service/surgery was performed.
  • Review previous notes/ correspondence to ascertain the global period. If information is not available call the insurance to validate if this claim falls into the global period.
  • Review if the Diagnosis code is related to the major surgery. If not, call the insurance company and have the claim reprocessed.
  • If it is not pertaining to the above conditions balance needs to be adjusted based on the client specifications.

5) Human errors – Denials Management in Medical Billing:

Scenario 1: Claim denied as Untimely filing/Appeal

  • Review previous notes, date of first submission to ascertain when the first submission was done. If the first submission was after the filing limit, adjust the balance as per client instructions.
  • If claim history states the claim was submitted to wrong insurance or submitted to the correct insurance but not received, appeal the claim with screen shots of submission as proof of timely filing(POTF) and copy of clearing house acknowledgement report can also be used.
  • If we have clearing house acknowledgement date, we can try and reprocess the claim over a call.
  • Reach the appeals department and follow up, if its already sent.

Scenario 2: Claim denied as Duplicate claim/Duplicate Charge.

  • Review the application to see if the same DOS for this patient with same Provider, CPT, DX and Modifier were billed.
  • If same DOS already paid, then adjust the duplicate claim.
  • If not paid adjust one of the charges as duplicate charges in error and review the other charge to understand the actual status of the claim. If any denial/correspondence/previous notes available, follow the protocol based on the details.
  • If there are no exact duplicate charges, the denial is due to duplicate submission. Review submission details to ascertain if the claim actually submitted again. If not, the denial could be for a different provider. In that case, call insurance company to understand the actual denial of the claim. If the rep insists the claim was for different provider send the claim for reprocessing. If the rep refuses check if we can add a modifier or appeal the claim to get paid.
  • If this was a service provided by two different providers and the denial is due to correct claim submission, call the payor to reprocess.
  • If modifier was not appended in the corrected claim, append correct modifier and submit the claim.
  • If previous notes states appeal is already sent, call the insurance company for appeal status.

Scenario 3: Claim denied as Need EOB/ERA to process:

  • Review to ascertain the payor who has sent the denial is primary or secondary.
  • Review other DOS to ascertain the insurance priority.
  • If the payor is marked as secondary, swap the insurance and submit the claim to the correct primary insurance.
  • If the payor marked as primary, contact the patient to update COB information with the insurance (Follow the protocol for COB).
  • If other DOS were paid by the same insurance as primary, call the insurance and reprocess the claim.
  • If there is a payment from primary insurance and the denial is received from secondary insurance, resubmit the claim with primary EOB/ERA to the secondary insurance.

Scenario 4: HCFA returned:

Review the claims mailing address of the insurance. If we have valid insurance, correct the address and resubmit the claim.

Research for correct claim mailing address, update and resubmit the claim.

6) Service related Complications – Denials Management in Medical Billing:

Scenario 1: Claim denied as need medical records/office notes to process the claim:

  • Review EOB/ERA to ascertain the exact medical record that is required. If not available, call the insurance to get the information required.
  • Based on the requested information, submit the requested record to the insurance.

Scenario 2: Claim denied as Not Medically necessary:

  • Review other DOS for this patient to ascertain if same CPT/DX were paid previously. If yes, call the insurance and have the claim reprocessed.
  • If no previous DOS were paid, submit an appeal with medical records.
  • Call the insurance for appeal status if already sent as per the previous comments.

Scenario 3: Claim denied as CPT/DX incompatible.

  • Review other DOS for this patient to ascertain if same CPT/DX were paid previously. If yes, call the insurance and have the claim reprocessed.
  • If not previous DOS were paid, send the claim to coding to review the correctness of CPT/DX. Call and follow up if previous comments states appeal already submitted.
  • If insurance rep refuses to reprocess, submit an appeal with medical records.
  • If coding suggest alternative codes, update the codes and resubmit the claim as corrected claim.
  • Call and follow up if previous comments states appeal already submitted.

Scenario 4: Claim denied as Invalid/Incorrect Modifier.

  • Review other DOS for this patient to ascertain if same CPT/DX were paid previously with the modifier in the claim or without the modifier. If yes, call the insurance and reprocess the claim.
  • If no previous DOS were paid, send the claim to coding to review the correctness of CPT/DX/Modifier. Call and follow up if previous comments states appeal already submitted.
  • If insurance rep refuses to reprocess, based on the EOB/ERA/previous submit an appeal with medical records.
  • If coding suggest additional modifiers, update the modifiers and resubmit the claim as corrected claim.
  • Call and follow up if previous comments states appeal already submitted.

Scenario 5: Claim denied as Incorrect/ Invalid Dx.

  • Review other DOS for this patient to ascertain if same DX were paid previously. If yes, call the insurance and have the claim reprocessed.
  • If not previous DOS were paid, send the claim to coding to review the correctness of DX. Call and follow up if previous comments states appeal already submitted.
  • If insurance rep refuses to reprocess, submit an appeal with medical records.
  • If coding suggest alternative codes, update the codes and resubmit the claim as corrected claim.
  • Call and follow up if previous comments states appeal already submitted.

Scenario 6: Claim denied as Incorrect/Invalid CPT.

  • Review other DOS for this patient to ascertain if same CPT were paid previously. If yes, call the insurance and have the claim reprocessed.
  • If not previous DOS were paid, send the claim to coding to review the correctness of CPT. Call and follow up if previous comments states appeal already submitted.
  • If insurance rep refuses to reprocess, submit an appeal with medical records.
  • If coding suggest alternative codes, update the codes and resubmit the claim as corrected claim.
  • Call and follow up if previous comments states appeal already submitted.

Scenario 7: Claim denied as Invalid/ Incorrect POS (Place of Service).

  • Review other DOS for this patient to ascertain if same CPT/DX/POS were paid previously. If yes, call the insurance and have the claim reprocessed.
  • If not previous DOS were paid, send the claim to coding to review the correctness of CPT/DX/POS. Call and follow up if previous comments states appeal already submitted.
  • If insurance rep refuses to reprocess, submit an appeal with medical records.
  • If coding suggest alternative codes (CPT/DX/POS), update the codes and resubmit the claim as corrected claim.
  • Call and follow up if previous comments states appeal already submitted.

7) Payment Complications – Denials Management in Medical Billing:

Scenario 1: Paid not posted/Incorrect address:

  • If the payment was made more than 30 days and EOB/ERA is not available, check website to download the EOB/ERA and sent it to payment posting team for posting.
  • If website is not available, call insurance to get a copy of EOB/ERA.
  • If the previous notes state the payment was sent to incorrect address, call the insurance to stop payment and reissue the payment to correct address.
  • If the insurance rep insists that the address they have paid is the same in their system, send W9 form to update the address.

Scenario 2: Paid to Patient:

  • Review notes of other DOS if the same insurance and same provider were paid to our address. If yes, call insurance and ask them to reprocess the claim.
  • On review, if it is found the provider is not contracted and payment is made as per patient plan, bill the balance to the patient.

Scenario 3: Applied to Overpayment or Offset

Scenario 4: Capitation:

  • Review all claims for this provider for this insurance to understand if he is covered under capitation.
  • Review client specifications on capitated providers, service capitated and the date span when the provider is capitated.
  • If the provider is capitated and the DOS is within his enrollment period, adjust the balance.
  • If the provider is not capitated for the DOS, call insurance to reprocess the claim.

Scenario 5: Primary paid maximum

  • Check the application to see if the balance is pending with secondary. If the insurance in question is primary, call insurance to reprocess the claim.
  • If it’s from secondary Insurance, check fee schedule of secondary to understand the allowable.
  • If the primary payment is equal to or greater than secondary insurance allowable, adjust the balance.
  • If the payment is less than the secondary insurance allowable, call the insurance and reprocess the claim.

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