ED Coding and Reimbursement Alert

Compliance:

Use This Advice to Declare Preemptive Strike on Denials

Published on Fri Aug 11, 2023

With procedures in place, you can reduce denials.

Claims denials can be exhausting for any medical practice. If you’re experiencing a lot of denials, there are ways to prevent them before they occur.

What? You may find the numbers surprising, but industry averages report that nearly 20 percent of all claims are denied. The good news is that as many as two-thirds of rejected claims are recoverable, and nearly 90 percent of denials are avoidable.

Check out this primer on how to bulwark your practice against the waves of potential denials.

Focus on Details

Denials have been steadily increasing since 2016, says Holly Ridge, BSN, RN, CPC, CPMA, manager of medical necessity and authorization denials for Duke Health in Durham, North Carolina. Reversing this trend starts with in-depth knowledge of codes and coding guidelines.

Keep in mind: “There are people in the office that don’t understand that if there are seven characters required, that there may be placeholders needed for the fifth and sixth character to get that to a D or S,” said Jennifer Swindle, RHIT, CCS, CCS-P, CDIP, CPC, CIC, CPMA, CFPC, CEMC, AAPC Fellow, in a presentation titled “Top Denials and how to work them effectively and prevent them in the future” at AAPC’s 2023 virtual REVCON. Coders, as specialists, must lead the charge, as their knowledge of persnickety details is crucial to success.

Recognize Chain of Events

Sometimes, denials happen because too many dominoes fall. Having a set-in-stone, comprehensive policy of verifying patient insurance can forestall a host of denials.

One of the most common times you’ll see a timely filing denial is when you file to the wrong payer, Swindle says.

For example, a claim may get denied because it wasn’t filed in a timely fashion — but then you find out that the claim was actually filed with a payer that no longer covers the patient. So, by the time the billing staff figures out what went wrong, the claim submission to the correct, current payer is no longer timely.

Remember: Payers set their own rules about when claims must be filed, so you (or your billing staff) need to keep the rules straight for each respective payer — and claim.

In this situation, some payers may provide a little grace if you can produce some proof.

If you can produce documentation proving that the claim was sent and received by a payer within the allowed timeframe, that gives you “a little bit more leg to stand on, to show, ‘hey, we did our job and we got this out the door,’” Swindle said.

It’s crucial to make sure you’re monitoring the claims you submit, because some timely filing denials may be your responsibility, even if you got them out the door on time and to the correct payer.

“Sometimes payers say, ‘We didn’t get a claim.’ You sent it, you’ve got records in your system, you show where the claim was generated — but they never received it. If they didn’t receive it, and you get a timely filing denial, that’s still on you, because they didn’t have it. So, you want to really monitor those,” Swindle warned.

Use Hard Copies With Caution

While a lot of payers accept claims electronically, some providers and payers use hard copies. Mailing records involves several situations where things can go wrong and result in a denial.

Swindle suggests people submitting paper claims and receiving denials on those claims should check these data points:

Are you sending things to the right address?
Is it going to the right department at that address?
Does the right person receive it, who can and will advance the claim to the next step in the process?

If you have a payer that routinely says they’ve not received claim submissions, consider sending some claims via certified mail. “I certainly don’t recommend that you send everything certified. It can get very cost prohibitive if you’re doing it on everything you’re sending,” Swindle noted.

If you don’t have that certified mail signature as evidence, it’s almost impossible to prove that you mailed a claim, she explained.

Make Sure Modifier Usage Is Correct

Modifiers can impact many facets of documentation, but their impact on the revenue cycle may be outsized. “Modifiers can be a problem if they’re overused, misused, or not used. All have a different risk,” Swindle said.

Reporting a service without the correct modifier may lead to denials with explanations like the service being inclusive with another service, services integral to another service, services bundled, and services not payable with another service.

Working knowledge of appropriate modifier usage, including being aware of any National Correct Coding Initiative (NCCI) edits, is crucial for getting claims paid. And remember, even in situations where a modifier is allowed, it may still not be appropriate, but any modifier usage can and should be supported by documentation.

Swindle noted that modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) usage is particularly scrutinized, and providers may be notified that they’re using modifier 25 more than their peers.

You need to make sure you’re doing it right, but just because your provider gets “a letter that says ‘you’re using modifier 25 more than your peers’ absolutely does not mean that they should quit using it. If they’re using it appropriately, and their services are supported, and their documentation supports it, it doesn’t matter if they use it more than their peers,” Swindle said.

“We want to make sure that we’re not using modifiers to get paid when it’s not appropriate that we get paid. But we want to make sure we’re using modifiers when we need to, to get appropriate reimbursement,” she said.