Practice Management Alert

With Medicare rates plummeting, Medicaid falling apart, and managed care groups continuing to dominate the healthcare marketplace, billers can't afford to let good claims get denied for bad reasons.

Improper denials can be the bane of a practice's existence. They're an administrative hassle something everyone would rather put off and not think about. However, they also represent hard-earned money that isn't making it into your accounts, and experts say you should buck up and contact the carrier or insurer to obtain your rightful reimbursement. Many managed care plans are shrinking the time frame providers have for filing claims. Beginning a few years ago, Tammy Tipton, president of Appeal Solutions, Blanchard, Okla., noticed "a really big spike in the number of 'lack of timely filing' denials."

"If you determine that you filed a denied claim properly, you should appeal with all your might," Tipton says. Don't Take It on the Chin Act Quickly When faced with a denial that you believe is improper, follow these steps:

Verify the reason for denials. Remember that there are two sides to every story, says attorney Alice Gosfield of Gosfield and Associates in Philadelphia. "It is possible that the carrier has erred" by failing to pay claims for covered services or by misinterpreting its own rules but practices "sometimes misinterpret the rules themselves," Gosfield says. Make sure you're up-to-date on the Correct Coding Initiative's (CCI) edits. The CCI edits come out every three months, says Arthur Di Dio of Arent, Fox, Kinter, Plotkin and Kahn in Washington. So make sure you didn't overlook a new edit. You should also see if the insurer's coverage policy has changed, or if a local medical review policy (LMRP) has been issued, changed or revised. Involve the clinician who performed the service in question while you do all of this homework. Tom Bouvia of Medical Management Resources Inc., in East Syracuse, N.Y., says that working closely with physicians is integral to the process. Bouvia says that in some states you can research online the Medicare carrier's bulletins about certain codes. If you find a coverage bulletin about the code in question, and the bulletin says you can bill for that code only if X, Y and Z apply, show this to your doctor. Maybe the physician will realize that only X and Y applied to the case for which he billed, and therefore he was wrong to bill it. Or, the physician may be able to help you better understand the bulletin, pointing out why he was right to bill and why the carrier was wrong to deny. File an appeal if you still can't understand why the claim was denied, Di Dio recommends. Even if you don't want [...]