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Your Questions Answered: Claims Denials

This is the first in a series of articles that will answer some commonly asked questions about different aspects of the revenue cycle.

Today, more than ever, practices are focusing on ensuring they have a strong revenue cycle – this includes making sure denials are minimized and appealed when appropriate. Today, we are answering some of the most commonly asked questions about denied claims and the appeals process:

  • If payers have proprietary edits, do providers have to accept it when they are told the denial is based on these edits or is there a place to check to see if the denial is correct?­ Obtaining proprietary information and edits from payers can be difficult at times. The best course of action is to submit your assignment of benefits and indicate that this agreement allows you to act on behalf of the patient. Since this is on your own policy with the payer, you would expect them to explain how that benefit was applied and calculated. If that does not persuade the payer to explain the denial, you may have to get the patient involved so that they can pursue their appeals.
  • How do practices appeal denials when the payer says they are paying on usual and customary reimbursement (UCR discount) when the provider is not in network and the EOB does not state that it is not the patient’s responsibility? UCR discounts are a big part of payer disclosure because you need to clarify if the claim was correctly paid and who is responsible for the account balance. The first step is to get disclosure and find out if this is a UCR reduction that has been applied. According to legal statutes, the payer must disclose what UCR reductions are, how the payer calculates these discounts and what type of data it is based on. Additionally, this disclosure will help providers clarify what they can do with balance billing – such as appeal it or bill the patient for the balance.
  • Where do you find the National CCI Quarterly Code Change Report? This report is on the CMS website, however it is broken down according to a range of specific codes. By accessing CMS’s Physician Center, you can select and review a range of codes. Unfortunately there is no place on CMS’s website where the entire report can be downloaded.
  • How do you eliminate the “Just write it off” mentality of some employees? This can be an important part of ensuring your bottom line does not suffer. One of the best methods is to track write offs and have processes in place for when accounts can be written off – such as having a manager sign off on specific dollar amounts or even having a manager sign off on all write offs. Practices should also review write offs, and if something is collectable they should go back to the team member who authorized it and show them that the practice could have appealed it and earned revenue. This will help illustrate how collecting on this account will help the bottom line and demonstrate how writing off items has a negative impact on the practice.
  • What is the best way to allocate work in billing, collections and denials? By duty or by payer? Although it depends on the practice, typically it works best to separate duties based on payer. This allows each person to know the payer fully and focus on the nuances of each payer.

Do you have a revenue cycle question that you would like answered? Leave us a comment and we will answer it in an upcoming post.