Chapter 2 Denials Flashcards
Once a claim is submitted to an insurance carrier, it is followed through until a payment or a denial is received.
*Payments are posted to the specific date of service, along with any necessary contractual adjustments. Remaining balances are sent to the secondary insurance or the patient is billed for the patient balance due.
*If payments and adjustments are not applied to the specified date of service, the effort to collect on remaining balances is greatly increased.
Once a claim is submitted to an insurance carrier, it is followed through until a payment or a denial is received.
*Payments are posted to the specific date of service, along with any necessary contractual adjustments. Remaining balances are sent to the secondary insurance or the patient is billed for the patient balance due.
*If payments and adjustments are not applied to the specified date of service, the effort to collect on remaining balances is greatly increased.
Working a Denial
Claims are denied by insurance carriers for many different reasons. Sometimes it will be a simple fix to correct the claim and other times it will take some additional work.
*After a claim has been denied, it is important to “work the denial.” Here are some steps to take when working the denial:
Determine why the claim was denied.
*The first step in working a denied claim is to understand why the claim was denied.
*Insurance carriers will use different denial codes on the RA to indicate their reason(s) for nonpayment.
*Denial codes may also be referred to as adjustment codes. These codes communicate why a claim might be paid different than billed.
Claim adjustment reason codes (CARCs)
CARCS communicate an adjustment, meaning that they indicate why an entire claim or a service line(s) was paid differently than billed.
*If there is no adjustment to a claim/line, then there is no adjustment reason code associated with that claim/line.
*The claim/line should then be paid in accordance with the contract between the healthcare provider and the payer.
*If the claim is not paid as expected or you are unable to determine why the claim has been denied, contact the insurance carrier.
*The national adjustment codes can be found at https://x12.org/codes/claim-adjustment-reason-codes.
Remittance advice remark codes (RARCs)
(RARCs) are used to provide additional explanation for an adjustment already described by a CARC or to convey information about remittance processing. Each RARC identifies a specific message as shown in the Remittance Advice Remark Code List.
There are two types of RARCs:
supplemental and informational.
The majority of the RARCs are supplemental; these are generally referred to as RARCs without further distinction. Supplemental RARCs provide additional explanation for an adjustment already described by a CARC.
*The second type of RARC is informational codes; these RARCs are all prefaced with the word Alert: and are often referred to as alerts.
*Alerts are used to convey information about remittance processing and are never related to a specific adjustment or RARC. RARCs can be found at https://x12.org/codes/remittance-advice-remark-codes.
Contact the insurance carrier with questions.
Sometimes, if the error is a processing error by the insurance carrier, a call to the insurance carrier may resolve the denial. If you are unsure of the reason for denial, contacting the insurance carrier may help to identify what needs to be corrected.
Correct the information.
If the claim is denied due to incorrect information on the claim, correct the claim and resubmit it to the insurance carrier using their corrected claims process.
Resubmit or appeal the claim.
Once the claim information has been corrected, the biller submits a corrected claim.
*If, however, the information on the claim is correct, but the claim should have been paid, the biller submits an appeal/reconsideration. Some carriers have specific forms and appeal processes to follow.
*Check with the insurance carrier to determine the next correct course of action.
Track the details and stay organized.
Make sure you are tracking the denials.
*Stay organized so that you can follow up on the claims easily.
*Any action taken by the biller on an open claim should be documented in the patient’s account.
*Some practice management systems will allow the biller to attach notes to a specific charge or date of service.
As you work denials, you may notice certain denial trends with the payers. If you find a higher volume of denials or the same issues repeatedly from one payer, it may be beneficial to escalate these through your provider advocate.
They (advocate) can review the problem for an issue at the insurance company and resolve it instead of you submitting appeals or reconsiderations for each claim.
*If you are not sure who your provider advocate is, reach out to your contracting department, if you have one, or start with your contact at the insurance company.
Common Denials
*Demographic denials
*Coding denials
*Benefit denials
*Back-end billing denials
Question: A patient comes in for several appointments and gives us an insurance as primary. That insurance pays as primary on all the claims.
*Two years later, the insurance carrier is recouping all payments stating another policy was primary.
*We called the patient and the patient gave us the insurance policy information.
*The new insurance carrier was billed and denied the claims for timely filing. What should we do?
Answer:
* Most insurance carriers will have a policy of what they will accept as proof of timely filing. For example, UnitedHealthcare’s Community Plan Quick Reference Guide states:
Claim denied/closed as “Exceeds Timely Filing”
Timely filing is the time limit for filing claims. Denials are usually due to incomplete or invalid documentation. Please include the following:
For electronic claims: Submit an electronic data interchange (EDI) acceptance report that shows UnitedHealthcare or one of its affiliates received, accepted and/or acknowledged the claim submission within the timely filing period. A submission report alone isn’t considered proof of timely filing for electronic claims. You must also include an acceptance report.
For mailed claims: Submit a screenshot from your accounting software that shows the date the claim was submitted. The screenshot must show the:
Patient name
Date of service
Submission date within the timely filing period
However, in this case, the proof will be the EOB received from the other insurance carrier showing the recoupment and denial. This information along with an appeal letter should be sent to the correct insurance carrier.
Coding Denials
Charge entry must be done on a frequent and timely basis. The process requires attention to detail and accurate data entry. After the service is performed and properly documented and coded, the procedure and diagnosis codes are entered for the appropriate patient, with the correct date of service (DOS), and assigned to the correct physician. After identifying the correct patient and physician, the next step is to enter the correct procedure and diagnosis codes that will attach a charge for the visit. Coding denials include denials for CPT® codes and modifiers, HCPCS Level II codes and modifiers, and ICD-10-CM codes. The denial could be the result of an invalid code or invalid code pairing. If these items are not correct, the result often is denied or delayed claims and potential risk for future audits. This service may be done manually in an office that uses paper charts or it may be done electronically by the physician at the time of the visit. Examples of coding-related denial codes are:
4 - The procedure code is inconsistent with the modifier used or a required modifier is missing.
5 - The procedure code/bill type is inconsistent with the place of service (POS).
6 - The procedure/revenue code is inconsistent with the patient’s age.
8 - The procedure code is inconsistent with the provider type/specialty (taxonomy).
9 - The diagnosis is inconsistent with the patient’s age.
10 - The diagnosis is inconsistent with the patient’s gender.
11 - The diagnosis is inconsistent with the procedure.
97 - The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
Question: When one of our patients has a condition that originates within the infant’s first 28 days, but the condition continues beyond 28 days, how is this reported?
Answer: Guideline I.C.16.a.4 notes that “Should a condition originate in the perinatal period, and continue throughout the life of the patient, the perinatal code should continue to be used regardless of the patient’s age.”
Question: Operative notes indicate that after a level-four evaluation and management (E/M) service for a new patient, the surgeon performed a surgical lateral release on the patient’s right knee. I reported 29873-RT for the release and got a denial. What did I do wrong?
Lateral release: If you reported 29873 Arthroscopy, knee, surgical; with lateral release with modifier RT Right side on the claim and the payer denied, it could be that you simply chose the wrong lateral release code. Go back and check that you have the proper code for the proper surgical knee procedure.
There’s also a slight chance that the payer denied 29873 because you used the wrong laterality modifier
there is also a chance that you should have coded the knee procedure differently. As the notes below 29873 indicate in CPT®, “For open lateral release, use 27425.”
