Practice Management Alert

Prevention is the best cure for denials and appeals.

Few businesses can afford to leave money on the table even in the best of times, and workers who are responsible for navigating healthcare claims, denials, and subsequent appeals can feel overwhelmed.

“Denials are increasing. This has happened year after year,” 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.

Remember: Denials are very specific, to a payer or even geographically, so evaluate your specific situation accordingly.

Identify Common Denials

Some practices may not think the resource investment required to appeal denials is worth the significant work costs. “Because of staffing issues, because of the work, a lot of times accounts do get adjusted off, because the dollar amount isn’t significant enough to pay for the appeals process,” Swindle said.

Practices should consider the amount of times these adjustments are made and evaluate how those costs bear out.

Claims are denied for a variety of reasons, but some reasons are more frequently seen.

Swindle lists these common denials: duplicate claims; patient has other primary insurance; the payer doesn’t cover the reported diagnosis; missing/incomplete/ invalid diagnosis; authorization issues; timely filing; modifier issue; the provider isn’t credentialed with a national provider identifier (NPI).

NPI credentialing can be especially tricky, because providers no longer backdate their services, Swindle said, so practices may have a tough time securing payment in the period between when a provider starts working at an organization and when their credentialing comes through.

However, not all payers use denial codes in the same ways, and the denial codes selected may not show what providers need to do to correct the claim. Swindle notes that staff need to be experts in navigating payers’ explanation of benefits (EOB) and payers’ websites, because they may need to be able to “read between the lines.”

Top tip: If you can develop a relationship with a payer via your representative, you may have an easier time of getting information that you need when you need it, Swindle said.

Double-Check Root of Duplicate Claim

“Duplicate claims may seem really easy,” Swindle said, but they can be really difficult because you always have to verify that there were two claims filed for the same provider and the same service, that it was an error on the organization’s part, and that the claims are truly duplicate.

“We don’t want to get any money that isn’t owed to us, but we don’t want to assume that money isn’t due because the denial code may say ‘duplicate claim,’” she said.

If the claim was corrected and made to an initial claim and refiled, but the bill type wasn’t updated, then the payor may not be able to see that the claim isn’t a duplicate.

Also, if you have a corrected claim but received payment on the initial claim, you may need to refund the money on the first claim so the payor can appropriately pay the corrected claim, she said.

You can adjust your billing system to trigger an alert to check whether a claim has already been filed for a service.

Coding tip: Appending the correct modifier can help curtail duplicate claims in some instances, like if a patient receives an EKG twice in the same day by the same provider or a different provider, she noted.

Incorporate Education for Staff

Having the wrong insurance on record for a patient can lead to denials, which makes sense, because carriers should be expected to pay only what they’re responsible for.

Make sure the staff interacting with your patients checks and verifies the patient’s insurance before an appointment. This is especially important because different commercial carriers may update their insurance at different times in the year — or the patient may have insurance coverage through an employer and thus their insurance may change with their employment.

“If it’s not being updated and verified, it’s very easy to send a claim out the door to the wrong insurance carrier,” she said.