Oncology & Hematology Coding Alert

Remember: Trend and track denials in your practice to find the root of the problem.

During her Virtual HEALTHCON 2020 presentation “Decrease Payer Denials for Increased Revenue,” speaker Stephanie M. Sjogren, CCS, HCAFA, CPC, CDEO, CPMA, CPC-I, shared expert advice to help you prevent denials in your practice. Suggestions include having a provider advocate, creating detailed payer contracts, and trending and tracking denials.

Read on to learn how to prevent claim denials in your oncology practice.

Create Detailed Payer Contracts

Composing detailed and straightforward payer contracts is essential to your practice’s success, says Sjogren. Follow these steps to establish flawless claims in your office:

Step 1: Make sure the contract is clear. If the contract doesn’t make sense to a person who has never seen it before and doesn’t have experience in your specialty, then a claims processor probably won’t understand the contract either, according to Sjogren.

When you create your payer contract, it is configured into a payment system. The people who configure the systems are not the same people who create the contract. The simpler your contract, the better off you are because the more complicated your contract, the greater chance for errors, Sjogren says.

Step 2: When you have case, per diem, or other inclusive rates, make sure you are forthright about what is included and not included in those rates.

You should always include specific CPT^®, revenue, and HCPCS Level II codes in your contracts, when appropriate, Sjogren adds. Also, “do not be afraid to advocate for non-standard language.”

Step 3: Once your contract is implemented and has taken effect, watch all of your claims carefully. You should check calculations and payment rates to ensure you are receiving the correct reimbursement, according to Sjogren.

Step 4: Understand your network requirements because they are a key component of contracts, Sjogren says. First, know which network you participate in. Also, your contract should clearly state which networks the providers can participate in and the requirements they must meet to join a network.

Step 5: Know the process for contract termination. Your contract should clearly define what date the contract starts, ends, and under what circumstances a provider and payer can terminate their agreement, according to Sjogren. Your contract should also state what constitutes as a breach of contract, such as referring out of network.

Always Have a Provider Advocate

You should also have a provider representative, advocate, or other direct contact at your payer, Sjogren says. Get a specific name of someone you can contact via phone or email.

“Mistakes and misunderstandings in configuration, testing, deployment, contract ambiguities, and edits will cause denials,” Sjogren explains. If you call the provider resolution number, they may go over one or two claims with you, but they might not understand that the problem is a pattern.

“If necessary, stipulate in your contracts that you will have a contact outside of the provider helpline available after traditional routes of contact have failed,” Sjogren adds.

Carefully Conduct Denial Research

When you research denials and trends, always ask questions and request details. “This is where the provider representative is paramount in helping you complete the task more accurately than the call center,” Sjogren says.

Examples of questions you can ask include the following:

Question 1: Do you require modifier RT (Right side), modifier LT (Left side), or other anatomic modifiers on this code?

Question 2: Do you have any diagnosis code restrictions?

Question 3: Do you have a medical or reimbursement policy that states your rationale for restricting a diagnosis, treatment, procedure, or other criteria?

Question 4: Are your edits sourced to the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA), or any other professional associations?

You should always be specific, Sjogren reiterates. “If you have a denial that is not sourced to anything you can find on the payer’s website, through AMA, Medicare, or the LCD/NCD, you want to ask for its rationale and source.”

Sjogren also emphasizes you should never immediately appeal a denial.

Many of the payers only give you one appeal chance, and you don’t want to waste that chance on a question, Sjogren explains. Oftentimes when they answer the question, it will be generic, and you won’t have any more rights.

Remember: “Any health plan must make available, upon request, and in some cases publicly, the details of any policy or edit that will result in a claim denial,” Sjogren says.

Trend and Track Denials in Your Practice

Since you can count on denials for many general reasons such as coordination of benefits (COBs), eligibility, or authorizations, you should train the front-line staff in your office to handle these issues proactively to avoid unnecessary denials, Sjogren says.

You should also trend and track your denials, Sjogren explains. Categorize your denials and who will handle them.

You can follow these simple steps:

• Look at overall trends and possible correlations between multiple denials to see if you can find the root of the problem. You should not rely on a customer service representative to do this for you, but if you do call the customer service line, you should ask them what denial codes they are using, Sjogren says.
• Become familiar with the payer coverage policies and make sure you are providing the necessary documentation.
• After you’ve found the root cause of the denial, you can quantify how many of that denial code you are seeing.
• Next, run a claims report based upon the data you found. “If you have more than 5-10 claims with the same or a similar issue, do not call to have each one reprocessed,” Sjogren says. “Instead, contact your provider advocate and work on finding a mutual agreement for claims processing and fixing the root cause issue.”
• Follow up with your claims reports to ensure the issue has been fixed and straggler claims have received manual intervention.

Editor’s note: Want more great info like this? Early bird registration is now open for 2021 HEALTHCON in Dallas, Texas March 28-31: http://www.healthcon.com/.