Medicare Compliance & Reimbursement

Excessive appeals often alert payers to fraud.

Denials are inevitable in the business of medical billing. Ultimately, how a billing practice handles a denial is up to the discretion of the provider and the officer manager. However, sending appeals to a payer when the documentation does not support the coding not only will cause the appeal to be denied (again), but could alert the payer that the practice has been billing erroneous claims. Enough of these red flags could increase the likelihood of an audit.

When an appeal includes documentation that does notsupport the coding, the practice is telling the payer that not only have they not documented what was coded in this instance, but perhaps this is a pattern, and may represent improper payments from other claims.

Submitting appeals in situations like this could result in the insurance company systematically denying all services of this type in the future. This could not only cause an increase in denials, but also could result in the practice being referred to the payer's fraud investigations unit for further review.

While the risk of an audit is the primary concern with this philosophy of appealing everything, there are other factors to consider, as well. Streamlining the medical billing process is a crucial component in making sure claims are submitting in a timely and organized fashion. Depending on the number of claims your practice handles, appealing every denial is simply not practical if you wish to keep on top of current claims.

As you become more familiar with an insurance company's guidelines and regulations, you should begin to better understand how to prevent particular denials from reoccurring. One way to help prevent denials is to update your practice's coding guidelines.

For example: If you know that a particular insurance company will not accept a particular ICD-10 code for an E/M service, make sure each coder is aware of a change in the guidelines when billing out to that insurance company.

Another idea: If you do not feel a procedure is being reimbursed fairly by a private payer, consider the option of having a meeting with the payer's medical director in hopes of renegotiating the physician's contract. This is not necessarily an easy or quick fix, but it can be extraordinarily beneficial to the practice down the road.