Coding denials are frustrating. You’re just seeking reimbursement for services provided, and your ultimate goal is to be paid quickly and at a maximum rate. Denied claims throw a huge wrench in this goal, especially if there are high volumes.
Did you know that according to MGMA, it costs providers $25 per claim on average to work and correct a denied claim? How do you prevent this expense? Simple. Analyze your coding denial trends and correct at the root of the problem.
Here are three questions you should be asking when analyzing the source of the denials:
- What tools are currently at your disposal to help correct the issues before the claim is submitted to the payer?
- Does additional education need to be provided to your providers, coders and A/R staff to prevent the denials?
- Are your payers denying claims for coding inappropriately? Or, are there other issues your payers should be considering to support the reasons why your organization (and likely others) should be able to bill charges?
Tools: What kind of tools? First and foremost, take a look at your practice management and EDI claims submission systems to see if they can be of assistance. Many of these systems have the ability to create edits if certain situations occur. For instance, Medicare does not pay for consultation services and requires providers to bill under another appropriate Evaluation and Management (E/M) Code. Can you set up an edit in your system that catches a consultation charge when attempting to bill Medicare when they are the primary payer for the patient? If not, there are many tools you can purchase to help prevent coding denials.
Education: Analyzing the coding denials can identify human errors. Forgetting to append necessary modifiers or to sequence them correctly will cause a denial. What is the source? Perhaps your providers select and bill their own charges through an Electronic Medical Records (EMR) system and don’t know the correct use of the modifier. Or, your charge entry staff may be entering the modifiers inappropriately. Have your certified coders audit the work of the physicians/charge entry staff regularly to provide continuing education and training.
Payer Corrections: Do your certified coders simply not agree with denials you are finding from the payers? If so, challenge the payers to accept the coding in the future. Just because a payer denies a claim, it doesn’t mean the payer is correct. Perhaps the payer needs to update their billing/coding policies. Your feedback and supporting research can help lead the change for not only your organization, but many others as well.
It is much more cost effective to correct errors before the claim hits the payer on many levels. You may shift some expense from the back end to the front end; however, cost will decrease overall, reimbursement will come in more quickly, and your A/R and days in A/R will be positively impacted.