Denial Management –A Review of the Reasons Given and the Steps Taken To Obtain Reimbursement.

 E/M Denial Management

Was the consult code billed either denied or changed to lower E/M level?

 What Documentation Is Required?

In order for an E/M service to be considered a consultation, the following criteria must be met and documented:

A request for a consultation, along with the reason for a consultation, must be documented by the consultant in the patient's medical record and included in the patient's medical record of the referring practitioner.

An opinion is rendered by the consulting practitioner. This opinion, along with any other service provided, is documented in the patient's health record.

A written report of the consultant's findings and opinion or recommendation is communicated back to the requesting practitioner. This report is known to include a thank-you letter for the consultation request and state exactly what the consultant's opinion is concerning the patient's medical problem.

CPT Assistant, July 2007 indicates that “there may be circumstances when a consultation is initiated by sources other than a physician, such as a physician assistant, nurse practitioner, doctor of chiropractic, … social worker, lawyer, or insurance company.” This helps to explain who can be considered another provider or healthcare entity. Reporting a consultation would be appropriate if the service was at the request of one of these professionals. -

Documentation is the key to getting paid for the consult done.

 It is a lack of proper documentation that leads to a carrier determination to downcode consultation codes to a lower E/M level of service or completely deny payment.

If you documented a consult properly and still received a downcode, appeal it immediately and attach the report made out to the referring physician.
Don't settle for the downcode amount when a consultation has been performed. Appeals that show full proof of the consultation performed will be reconsidered by the insurance carrier for the full payment due.

 

Spotting denial patterns can be an effective way of managing the denial issues that have affected reimbursement.

 Additional information was not sent in as requested from the carrier. Electronic submission of claims expedites the processing of payments for bills submitted in this format, however, certain codes will need to be submitted with clinical documentation records for carrier review. If the insurance carrier doesn’t receive the information requested within their allowable time frame, your claim remains denied. Review policy guidelines to know the time frames.

Some insurance carriers have a software program that are unable to recognize modifier usage.  If you have billed for another service during a post op surgical time frame, denials are issued because the carrier software program doesn’t recognize the modifier placed on your line charge. Often an online appeal or telephone appeal can clear this up. Should the insurance carrier request a written appeal for payment reconsideration, have a form prepared that you can easily type in the information or fill in. Fax or mail it out immediately.  

 High Deductible Amounts: More insurance plans are placing greater financial responsibility on the patient. This denial is more common. Advising the patient ahead of time can bring awareness to the patient and the opportunity to set up a payment plan. 

 Incorrect modifier usage- Depending on the carrier, some modifiers may or may not be acceptable when placed on a charge line submitted electronically. Check with the guidelines of the insurance carrier regarding claim submissions with modifiers. Also, the line charge on your submitted claim may have been missing a modifier. Review the billing and send in a corrected claim with the modifier attached to the denied charge.

 Data entry errors made by the insurance carriers for the codes billed and submitted by your practice. This happens more often than you think. And with ICD-10 in mind, this may become a more common denial on both the biller’s end and the carrier’s end since the codes are longer and contain both letters and numbers. Review the written denial carefully line by line for the codes submitted and compare it with the denial explanation sent to you and sometimes it is a simple data entry error that caused the denial.

 Provider not credentialed: If there were new physicians added to your practice but they are not yet credentialed or participating with the same insurance plans your practice is part of, contact your credentialing department to resolve this issue.

Certain codes cannot be billed to specific carriers. One example of this is the consultation codes. Check all your insurance company guidelines and let your billers know what insurance carriers do not accept consult codes.

 Claim Not On File

Send in your proof of a submitted claim to the carrier and call them as well. Get the names of the representatives you spoke to, advise them you are sending proof of submission which can be in the form of a copy of your electronic submission report of the claim and this time send it signed return receipt to the carrier for the claim. Document all “claim activity follow up” in a log regarding all actions to get this claim paid. Follow up with the carrier once your signed return receipt card is back on file with you. Most of the time this is enough proof to have the denied claim paid but sometimes it isn’t and then it becomes a matter that can be addressed with your state insurance department. Send in copies of your call log activity that includes the names of the people you spoke to at the insurance company and your proof of claim submission for all the times the claim was submitted. The State Insurance Department can be of great assistance with this kind of issue as well as other issues if a claim is unfairly denied.

 

No Coverage – Your office staff verified active coverage for the patient prior to medical services rendered but the denial states “no coverage”. This denial happens when the premium has not been paid by the patient. It is now patient responsibility.

 Build a bridge where you can and establish a good rapport with the insurance company representatives.

Phone communications go along with payment review considerations. If an appeal has been sent to the insurance carrier on their website or mailed in, there should be phone contact to follow up and make sure your paperwork was received. Good communications often lead to good results. Get to know the claim representatives name and contact number. Establishing contacts and building relationships with representatives at the companies you contact, can help expedite the appeal process of your claims.

 Claim Tracking Reports

 Your medical billing software program should be able to run reports on specific codes or for insurance carriers to see why you aren’t being properly reimbursed for the medical services provided. A dedicated staff in your billing department should be able to help identify and address the denials that come in.  All denial management actions should be documented and addressed with the carrier as soon as possible because of time frame limitations set within the policies of the insurance companies. Most denials can be turned around if the denial reasons are understood and acted upon immediately. Delay leads to more delay so one of the keys to obtaining reimbursement after a denial is issued is to act fast when it is known why the denial was placed on your claim.

 

Julie Pisacane, CCA, CPMA, CEMC            7/16/15