Medicare Compliance & Reimbursement

Your claims could be on this carrier's greatest hits list.

This is one "top 10" chart you don't want to find your services on. Part B carrier Trailblazer Health Enterprises issued its list of the most common denial reasons for the fourth quarter of 2006. Use the following checklist to avoid familiar pitfalls:

1) Duplicate claims in which you have resubmitted a claim that the carrier already processed and made a zero payment on because of a denial or because the patient hadn't met his deductible. Or else, you may have "automatically" resubmitted the claim if you hadn't received payment within 30 days of filing it.

What to do: Check your claim status before refilling a claim. Call your carrier to check on the reason a claim wasn't paid the first time, and to verify your claims processing information, Trailblazer advises.

2) Beneficiary ineligibility because the Medicare number is invalid, the patient isn't eligible to receive benefits, or you should have billed other services first.

What to do:If you're seeing these denials, screen your patients and check on their Medicare effective dates.

3) Incorrect carrier. What to do: Make sure your patient doesn't have a Medicare managed care plan or railroad Medicare.

4) Bundled services. What to do: Check the fee schedule database to see if a particular service is "Status B."

5) Medical necessity. What to do: Check national and local coverage determinations, and also make sure your diagnosis codes correspond with your documentation. If necessary, obtain a valid advance beneficiary notice (ABN) before billing.

6) Medicare secondary payor. What to do: Make sure another payor doesn't cover this patient.

7) Non-covered services. What to do: Make sure the claim isn't for a self-administered drug or another service that Medicare never covers.

8) Provider ineligibility because the date of service on the claim is before the provider's effective date or after the provider's termination date. What to do: Make sure you're using the correct date of service. If you have, then contact your carrier's provider enrollment office to see if there's a problem with the physician's effective or termination date.

9) Invalid modifier. What to do: Make sure you're using the most up-to-date list. For example, Medicare recently replaced the QB modifier (for Health Professional Shortage Area) with the AQ modifier.

10) A routine exam or screening procedure. What to do: Remember that if the patient has no symptoms or evidence of illness or injury, Medicare won't cover the service.