Lisa Rock, president, and Ryan Flesner, director of A/R, discuss five guaranteed ways to have your claim denied — and how to avoid those denials on the front end.
According to Mr. Flesner, errors from the patient ID card that go through incorrectly on the claim form could mean an instant denial. These errors could include mistakes in the ID number, date of birth or subscriber date of birth, and the mistakes can be easy to make because of the confusing nature of some ID cards. “For example, there might be three numbers on the card, and if they’re not identified by ID number and group number, the front desk person might have no idea which number goes where,” Mr. Flesner says. He says in order to ensure you catch these errors before submitting the claim, make sure your front desk staffers are entering ID card information correctly and understand how each carrier ID card is set up.
He says particularly confusing cards can be addressed with the carrier. “Sometimes you have to go back to the carrier — especially with PPOs because they have so many third-party payors they’re managing — and show them an example of a poorly formatted ID card,” he says. “The carrier will review that card for you and require the payor to change it.”
It is absolutely essential to make sure the patient actually has coverage before undergoing a procedure, Mr. Flesner says. If the patient does not have the required benefits, you will get a denial. While you check on benefits, you should always check the deductible to see if the patient has a “trash plan,” meaning a very low premium and a very high deductible. Mr. Flesner recommends you also remember to verify benefits in an outpatient surgery center rather than just outpatient — there is a difference.
Verifying insurance means contacting the carrier directly for information about the patient’s plan, the upcoming procedure, and the necessary authorization. During this conversation, the carrier can tell you the best way to submit the claim and where to send it to ensure it is paid. Mr. Flesner says some insurance companies track high-volume surgeries to ensure surgery is necessary for the condition. “Carriers are going to look for a history of a more conservative approach before they offer surgery,” Ms. Rock says. “That’s why authorization is so important for some procedures because maybe carpal tunnel doesn’t require authorization today but tomorrow it will.”
Coordination of benefits is as simple as making sure the patient’s primary, secondary and tertiary coverage — if applicable — are loaded correctly into the system, Mr. Flesner says. Many patients are unaware of which insurance plan is their primary and which is their secondary, and if you submit the claim to the wrong plan, you will receive an automatic denial.
He says when determining which parents’ coverage is the primary, some companies use the spouse with the birthday that falls earliest in the month — a fact that many patients are unaware of. “If mom was born in March and dad was born in February, they’re going to go with dad,” Ms. Rock says. “[Patients] are absolutely unaware and think they can pick and choose. If dad’s has a large deductible and mom has a $20 co-insurance, they think they can choose her plan as the primary, and that’s not how it works.”
Ms. Rock also warns ASCs to be careful of indicating an injury or illness is related to a motor vehicle accident. “There’s a spot on the claim that asks the provider if the injury or illness is related to a motor vehicle accident, and if you mark that box yes and you’re billing private insurance, you’re going to get a denial,” she says. “They’re going to want it to go to MVA first or at least want more information because if it looks like an injury, the private insurance is going to see if someone else is responsible for paying that bill.” In MVA cases, mark the claim form correctly and submit to the auto insurance first for any possible PIP benefits, Ms. Rock says. Only submit to the private insurance with a letter of exhaustion.
While Medicare and several large carriers use the federal NCCI edit system, some carriers use their own edit systems and bundle certain procedures that aren’t bundled by NCCI edits, Mr. Flesner says. “Not all insurance companies use the federal edit system, and some companies’ systems consist of a single doctor looking at large claims and deciding whether a procedure is incidental to the main procedure or not,” Mr. Flesner says.
In order to prevent your claims from being denied, Mr. Flesner says you need to know the edit system each carrier uses and the differences between that system and what your ASC uses. “This is a problem that has to be fought on the back end, just because you’re not going to change your ASC’s edit system to accommodate some doctor in an office,” Mr. Flesner says. He recommends using the federal edit system to give your ASC more leverage when appealing your claim. “I’m usually pretty successful when I battle a denial for bundling that’s in a system other than the federal edit system,” Mr. Flesner says. “You may choose not to use an edit system, but it puts you in a weaker position when you’re trying to fight those types of denials.”
Certain carriers have different preferences when it comes to modifiers, Mr. Flesner says, and your coders must know which carriers prefer which modifiers before they submit a claim. For example, he says certain workers’ compensation carriers prefer the -SG modifier on the claim, and certain carriers don’t want it. These modifier preferences can differ by carrier and by state, so coders need to do their research to avoid denied claims.
He says if your coders are unaware of a carrier’s preferred modifier, they can contact the carrier and talk about how the claim should be submitted. He also advises coders to learn from past errors. “Once you see a denial on the back end the first time, your A/R rep should be able to identify that denial and let the coder know which modifier the carrier wants,” he says. Don’t forget that carriers paying at the professional rate is also a type of denial. According to Mr. Flesner, modifiers or lack of can trigger carriers to pay ASC claims at professional rates.
Ref. Becker’s Healthcare
This post was first published October 25, 2010 and was updated July 29, 2020.