Medicare Compliance & Reimbursement

Question:

Trying to put through an incomplete or incorrect claim will probably result in an immediate denial, so don't waste your time doing so. Instead, put these claims on hold or suspend them, then do some homework on these claims soon. You'll be more likely to find the information you need to submit a clean claim.

Claims can be held or suspended for a variety of reasons. They may have a missing diagnosis code, a code that is no longer valid, or be missing important information. Luckily, most billing software allows you to hold or suspend claims that have such errors. After you suspend the claim in question, check the patient's medical record. The proper codes may be there, or you may have to check with the clinician if there is missing information in the chart. If so, let your provider know what information you should be seeing on the chart.

If the missing information is patient related, such as policy number, address of the payer, address confirmation, or referral, you should contact the patient and get the missing information.

Pointer: If you find that you're suspending claims frequently, it might be time to look into your practice's policies and procedures for suspended claims. If there isn't one, create one soon. Include policies for under what conditions you should suspend claims (like the ones mentioned above), guidelines on how soon the follow-up must occur, and a timeline for when suspended claims should be sent.