1. Coding Issues

• Medical Necessity-Additional Documentation Requested

Many payors require medical records before a claim will be adjudicated, including medical history, previous physical reports, consults from other physicians, reports from previous services received and operative reports to determine the medical necessity of the services performed. Medicare states that it will not cover services that ‘are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member’. Many other payers follow Medicare’s guidelines in determining Medical Necessity.

• Upcoding

Refers to intentionally using a higher paying CPT code to bill a health insurance payer to receive a higher reimbursement for a higher paying service than what was performed. This is illegal and considered a fraudulent practice.

• Unbundling

The practice of billing separately for components of a group of services that are normally included in the services performed to increase profits when the un-bundled services reimbursement totals more than the special reimbursement rates.

• Coding does not have enough specificity

With the onset of ICD-10 coding, each diagnosis must be coded to the highest level for the code used. ICD-10 allows for greater detail by describing primary and subsequent encounters, external causes of injury, preventive health, and socioeconomic, and lifestyle-related issues and has the capacity to accommodate evolving technology and supports exchange of health data.

2. Claims Issues

• Prior Authorization Incorrect or Missing

Many services require the obtaining of an authorization prior to certain services being performed. These are often payer specific and though not aguarantee of payment they are essential for payment to be considered. A strong prior authorization department and process is one of the most important in the entire revenue cycle department.

• Services not covered or coverage terminated

With the ease that persons can change their coverage, it is critical to verify eligibility each time a patient presents for services. Coverages for services vary from payer to payer and verification of maximum benefits for services such as behavioral health and physical therapy need to be verified to assure their caps have not been exceeded.

• Missing Information

Any missing information can result in a claims denial. The most common include date of accident, date of onset of illness, occurrence codes and medical emergency date.

• Duplicate Billing

Often the result of human error resulting from resubmitting a claim rather then filing it as a corrected or cancelled claim will eliminate these denials.

• Not Filing Timely

If a proper claim is filed but not within the prescribed timely filing window provided by the payer, a denial may result. Often these are not appealable so having a firm grasp on all contracted payers timely filing limits is essential in preventing these types of denials. Understanding what is required to submit when filing supporting documentation needed for claims adjudication, is critical to appealing a claim and appealing it timely.

• Inaccurate Patient Identifier Information

This may be the easiest of denial reasons to prevent. The correct patient information, including spelling the patients name correctly, accurate policy number, group name and number if relevant and patients correct relationship to the insured will prevent these types of denials.