As an RCM service provider, we see denials daily. These denials range from “improper diagnosis/procedure combination” to “inappropriate modifier assigned”. While these are sometimes difficult to catch prior to claim submission, the most common denials are the ones that are avoidable altogether, and, surprisingly, they are responsible for the consistent cash flow issues for many practices. We have comprised a list of those most common denials as well as what can be done to correct the problem before it becomes a problem.
- Missing or incorrect patient demographics – solution interoperability
- Procedure unbundling – this can be avoided by having a trained coder on your staff that is knowledgeable in following the CMS NCCI billing guidelines. This table can tell you prior to billing whether or not services are eligible to be reimbursed at the same encounter. This allows you the opportunity to assess the services that should be provided and form a treatment plan that meets the patients’ needs.
- Duplicate claim submission – this denial can be as simple as a claim being re-billed too quickly or as careless as keying the same charge twice. The claim will need to be traced back to the encounter form to see if the service was performed twice. If it was, and it is a service that allows for multiples, add the necessary modifiers and attach the notes to the claim for reprocessing. If it is a billing error, it should be adjusted off the patient’s record to clear the A/R. This can be avoided by making sure the necessary notes/modifiers are attached on the original claim. For errors in keying, implementing a balancing protocol for your charge entry staff will assist in catching these errors before the claims are submitted.
- Service already adjudicated – This usually indicates that an EOB has been issued to the provider. Assess your payers and implement ERAs at every opportunity. In today’s billing industry, so much is done electronically, and has proven to be very efficient. Most payers will allow for EFT and ERA set up, which allows for faster reimbursement as well as automated payment posting. It also eliminates much of the human error involved in the mailing of hard copies. Our RCM Division makes it a priority to set these options up for our clients to simplify and improve on the overall process.
- Services not covered by payer – This denial can be avoided simply by calling the payer prior to services being rendered. If a plan does not cover a specific service, and the practice didn’t inquire ahead of time, the practice stands to lose a lot of money from in-network payers. Getting pre-authorizations and doing benefit inquiries is a sure way to make sure you are getting reimbursed for all applicable services. Also, again, sometimes these denials are a result of not properly pairing diagnosis codes with CPTs. Our CPCs help ensure that this is caught as quickly as possible to avoid any disruptions in cash flow.
Time limit for claim submission has expired – As a billing provider, we see this denial in new customers frequently. This is a primary indicator that your follow up process is insufficient. This basically states that the claim was not received within the allotted time allowed by the payer. This time frame ranges by payer from 90 days up to 24 months. If claims are being entered and billed out within a few days of the actual date of service, there is no reason the payers would not receive them for processing well within the time limits. Therefore, either claims are not being entered and billed in a timely manner, which is an issue all by itself. Or, no one is following up to make sure the claim submission process is running smoothly. Either way, this is a rule that few payers will show any lenience on, but is also very easy to avoid with the proper precautions in place.
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