Why Are Medical Claims Denied?
Most medical claim denials in practices aren’t related to coding. Medical claims are most frequently denied because of:
- past filing limit
- lack of pre-authorization
Can Medical Claim Denial Be Avoided?
Yes, some of these reasons for medical claim denial can be avoided. I think of some of these denials as “never events.” A group should never—or rarely—have denials because of past filing limit, provider not enrolled or lack of pre-authorization. In practice, coordination of benefits or slow patient response coupled with a short filing limit can lead to being past the payer’s filing limit. Credentialing delays can lead to providers starting to see patients before all commercial payers have enrolled the provider. And, the group may have received the pre-authorization but this the authorization isn’t found by the payer on the first submission.
And, there are coding denials. There are many reasons for coding denials, some of which can be avoided, many of which can be corrected. But perhaps the most frustrating is when the practice follows CPT rules and the payer still denies the claim.
What Happens When Coding is Correct But the Payer Does Not Follow CPT Rules?
Whenever I speak to a group of physicians and coders, someone always tells me this, “We have a payer that doesn’t recognize modifier 57, and won’t pay it on appeal. What can we do?”
The question varies from state to state and year to year, but the core remains the same. A payer is systematically ignoring CPT rules in processing claims.
I recently posed this question to Elizabeth Woodcock during one of her excellent webinars about denial management. I’m going to paraphrase her response. Payers are required to use CPT and ICD-10 rules.
- The first step is to call your payer rep.
- No luck? Get in contact with a senior administrator at the health plan or the medical director. (I think if you’re contacting the medical director, the call or letter should be physician to physician.)
- Finally, avail yourself of external resources. Call the advocacy office of your state medical society or national specialty society. At the state level, sometimes legislators can help. And, if you’ve checked and double-checked your work and your resources, copy your state insurance commissioner.
So, don’t accept these denials without a fight.