Medical billing process - Action on denials

Very important process in Medical billing



DENIALS/REJECTIONS

Action on Regular Mails or denials

This is a most important function in the process flow of data. Unless this is taken care of, insurance AR will only be on an upward trend. Regular Mails contain tremendous source of information. We need to use the information not only to take care of the particular claim in question but also globally for all claims for the carrier and for all similar issues elsewhere.

Let us discuss in detail as to what are the types of issues that you would encounter in the regular mail:

Basic denials requiring corrections:

· Incorrect id # - This may be due to the following: (a) the source document may have an incorrect id. (b) data entry error (c) the id format may not be in the billing rule. If the denial is due to (a), then we need to document such denials and notify the client immediately. If the denial is due to (b), we need to find out where the breakdown is and why this has escaped the eyes of the

 charge entry person and audit. If the denial is due to (c) i.e. if the id # entered is not in proper format, then we need to immediately set up a billing rule which will trap this kind of error and we can correct the claim before sending it out in the first place.

· Incorrect or No modifier – This may be due to two situations: (a) the ignorance of the charge entry person as to what modifier should be applied for the particular procedure and (b) data entry error. In either case if a proper billing rule is set such that for these procedures this modifier should be used, then any charge without that modifier will not be generated as a claim. This can be identified before hand and corrected.


· Coverage not valid for DOS; Coverage Terminated; Benefits Exhausted – These are patient related. However if we had the effective dates of each coverage established, then the first two kinds of errors can be identified at the front end itself before the claims are generated. As regards the last one i.e. Benefits exhausted, this may be due to the fact that the patient’s policy will pay for a particular procedure only once during a year or once during a life time or the insurance company’s general rules for a particular procedure may be only once reimbursable. If it is the latter it can be identified beforehand by setting up a billing rule for that procedure and that insurance company. If it is patient policy specific, then this can be known only when we receive the denial. The ultimate solution for all these cases is to bill the patient.

· Non-covered services – The member’s policy does not cover the service provided. Here also we can bill the patient. However we cannot bill a Medicaid patient for this denial in certain states.


· Unable to identify patient – This may be due to two things: (a) the coverage details given in source document may be incorrect and (b) data entry error. If this is due to the latter, it may be due to the fact that the operator has entered the patient name or the id # or the insurance company number incorrectly. This is a serious error and we need to find out why the system had failed to track this. We should correct this and resubmit the claim immediately. If it is due to the former, then such errors need to be documented and notified to the client. However follow up needs to be done to correct the claim and resubmit.

· Require medical records or Denied for Medical Necessity – In the first opinion of the carrier, they may feel that the procedure may not be necessary for the diagnosis specified. Hence the request for medical records. We need to check the DX anx CPT combination if everything seems to correct then we should pull out the medical records from the charge file, take copies of it, attach it along with the claim with a covering letter and send it. Analysis should be done to resubmit all claims with the given procedure-diagnosis combination for the insurance carrier with medical records.

In addition to denials, we also receive News Letters and Manuals. News Letters are periodical publications of the insurance carriers, which they regularly send to providers. You will receive them in regular mail. They contain information such as the latest decisions by various medical bodies, new policies on medical care, changes in existing reporting requirements by providers and other rules and regulations. Manuals are published once a year with periodical updates by the insurance carriers. These contain the complete medical policies and billing information with respect to that carrier. It mainly contains the claim submission instructions for that carrier with respect to each specialty. We need to carefully store these valuable documents since they are references during the billing process.

1 comment:

Anonymous said...

Willingly I accept. The question is interesting, I too will take part in discussion.

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