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Are You Living in Denial?<
by: Robert Anthony
Proven Strategies for Reducing Claims Denial Did you hear about the insurance company that was losing money? The payer rejected every appendectomy claim it received for 30 days. Seventy percent of those denials were never resubmitted. The unclaimed revenue allowed the company to get out of financial trouble. Sound like a bad joke or a conspiracy theory? It's not. Sometimes it seems like payers will do anything to keep your money. But you shouldn't accept denials without a fight. "I see it time and time again with incorrect payments that are never argued. Business office people often have the philosophy of 'the payer is always right,'" says Rhonda Koehn, president of Reimbursements Managers, a medical billing company in Greeley, Colo. It's time to streamline your approach to reimbursement, anticipate payer problems, and learn ways to combat them. Medicare madness Did you know Medicare denies up to 22 percent of medical services, depending on the specialty? If you're in dermatology (the lowest denial rate, at 5.5 percent) or pediatric medicine (a mere 6.22 percent), then you're one of the lucky ones. But if you're an anesthesiology practice (with a daunting 18.55 percent denial rate) or an obstetrics and gynecology practice (the highest, with a whopping 22.42 percent), then Medicare denials can easily become daily occurrences. "The problem with Medicare is that you can talk to four different people and get four different answers," says Darlene Helmer, CPC, ANP-C, billing manager for Physician Anesthesia Associates of Towson, Md., and co-chair of the Third Party & Reimbursement committee of the Maryland Medical Group Management Association. "They don't always know their own regulations, so you have to be the expert on [them]." Being an expert on Medicare reimbursement isn't easy, but it's not impossible. Lori Winstead, insurance and collections manager for A Woman's View, an internal medicine and gynecology practice in Hickory, N.C., says that at least with Medicare, "you get a clear explanation of the denial." Knowing why a claim is denied can be half the battle. The other half is preventing denials. One of the most common reasons for denial is incorrect information. Both Koehn and Helmer see the same things occur repeatedly: incorrect identification numbers, CPT codes or modifiers in the wrong place, and names that are spelled incorrectly. "If your name is 'John A. Smith, Jr.,' and that's how it appears on your Medicare card, but the claim is entered as 'John A. Smith'- that claim will be rejected," notes Helmer. Though it wasn't always the case in the past, any name variation - no matter how minor - is now automatically rejected. The same holds true for identification numbers. Two digits that are accidentally transposed will result in a denial. Practices need to make sure they get complete and accurate information from patients at the time of their visits to avoid having to resubmit claims. Dealing with denials based on type of service can be trickier. Koehn recommends that at least one person in the practice become a Medicare guru. "I think the number one thing is to know the Medicare policies," she says. "So basically [practices] can take their top codes and search [Medicare's Web site] by CPT code or procedure description for any medical review policies that apply to that particular code." A certain number of Medicare claims denials are to be expected, but those specialties with the highest rates need to be extra vigilant. Take obstetrics and gynecology. Most denials are related to preventive service billing, "because Medicare has special codes they want for breast and pelvic exams instead of the normal well-woman exam code," explains Koehn. For providers who think the Medicare codes are insufficient, Koehn r< |
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