Denied a claim? Don't take "No" for an answer!

July 1, 2005



The single best way to maximize revenues is to collect all you're owed for the services you've provided. Yet, practices lose thousands of dollars each year because they don't appeal claim denials effectively.

Why don't practices pursue appeals? Sometimes because staffers lack the time or commitment, and denials end up in a folder to be looked at "later" or "when it quiets down." You know those times never arrive, and waiting is a sure strategy for failure. Denials should be worked on daily. Simple ones should be handled quickly over the phone, without ever generating a second claim. Claims with incorrect claim numbers or patient birth dates are easy to resolve that way.

To handle more complicated denials, your staff may need more education on coding issues. Some billers may not be up to date on the CPT and ICD-9-CM rules and can't readily tell when claims are denied incorrectly.

It's not always the payer's fault The ultimate goal, of course, is to get paid the first time you submit a claim. Coding accurately will ensure that. Many of your denials are issued for reasons that are under your practice's control. By keeping a record of denials, you have the data necessary to train your staff:

1. registration errors, such as incorrect subscriber health insurance number, date of birth, or eligibility

2. coding errors, including incorrect CPT codes, diagnosis codes that don't support the procedure, and modifier errors

3. payer processing errors, such as using edits incompatible with the National Correct Coding Initiative, known as NCCI.

Training, giving feedback to individuals based on specific errors, and more-detailed procedure manuals are three ways to reduce the number of denials due to registration errors. Of course, if you have high staff turnover or inadequately trained and supervised staff, those factors can increase registration errors.

Fix coding errors, and then learn from them. Using a claims-editing program is an effective strategy but, even with such a system, your staff has to know about the latest coding rules.

When services are denied because of an incorrect or unsubstantiated diagnosis code, review the medical record and compare it to your local medical review policy, known as LMRP. Is there another diagnosis code documented for that date of service that would substantiate your claim? If so, copy the note and resubmit the claim with the corrected diagnosis code.

What happened with a recent review of a practice occurred outside of pediatrics-in primary care-but is nonetheless instructive: The office routinely wrote off claims for HCPCS code G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination). All the claims were submitted with diagnosis code V70.0 (routine general medical examination at a health-care facility). Covered diagnoses for G0101 are V76.2, V76.47, V76.49, and V15.89. Billing the service with the diagnosis code for the general examination will always result in a denial.

Correct modifiers make a difference Services are often denied because they're submitted without a modifier or with an incorrect one. That situation often occurs when there's a minor surgical service performed during an office visit. Sometimes, such claims are submitted with no modifier or with the modifier (–25) attached to the surgical procedure instead of to the office visit. The insurance company denies the payment, and too often a staffer writes it off without questioning the reason. Those claims can be corrected and resubmitted; and they will be paid.