Clinical Review

Claim denials: How to raise your chances of getting paid

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Managing rejected claims after the fact is a losing game


4 reasons claims are denied

1 The payer includes it in a global package

2 Lack of preauthorization

3 Payer assumes the claim is a duplicate

4 Registration process involved an error

It’s the end of another long day, and your billing manager is in tears. For the third time this month, she is frustrated about the overwhelming amount of work in the billing office. “The staff simply can’t keep up!” she exclaims.

She wants to hire another biller. But you have spent considerable time the past few months brushing up on your coding expertise and renegotiating contracts with your key payers. So why has the billing workload increased so much? Why is your staff overwhelmed?

The problem isn’t limited to your practice. All types of medical practices face increased workloads in their billing offices. Quite often, the added work is from a single source—claim denials. If your billing office always seems overwhelmed, check the volume and types of denied claims. Many of the problems are preventable.

The solution to denials is not always to hire more staff. Too often, the billing staff focuses on managing denials after they happen, but that’s a losing game. Your first line of defense is to fix the problems that cause denials. Then identify strategies to prevent the denials and manage them when they do occur.

1Don’t accept bundling of stand-alone services

Many codes encompass a predetermined period before, during, and after the service you provide. ObGyns are most familiar with the coding for deliveries. For example, a claim for a service coded 59510 includes all routine obstetric care, be it antepartum, postpartum, or the cesarean delivery itself.

If this seems cut and dried, think again. What if the patient returns a week after discharge with a minor infection in the wound site? You’d document your service and bill for an appropriate-level office visit. Despite its merit, that claim might be denied and returned, marked with words such as “inclusive,” “global period,” or “bundled.” Regardless of the exact language, the payer is saying that payment for the service was included in another payment it made.

Train staff to question denials

In many practices, staffers simply accept denials. They write off the charge as a contractual adjustment for that payer, and the money is gone—even though you deserved it! Although many services you provide during a pregnancy can be legitimately included with other procedure codes, this one—and perhaps others you bill—is not one of those bundled services.

Two terms are important: global period and bundling of multiple services.

Global period is the time (0, 10, or 90 days, for example) during which any services you provide are included in the payment for the service. For obstetric services, that period includes antepartum, delivery, and postpartum care. For gynecologic surgeries, the period varies by the surgery. These periods of time—often called “globals”—are established by the Centers for Medicare and Medicaid Services (CMS) and are published annually in the Resource-based Relative Value Scale.

Bundling means that 1 service is identified as the primary service, and any additional services during the same session are included in the payment. That is, you get paid for the primary service only. CMS publishes a list of primary procedures and the procedures secondary to them in its Correct Coding Initiative, which is updated quarterly. However, many payers establish their own bundling rules.

Note when the global period begins. Let’s return to the example of the global obstetric package. Services rendered during this period are often bundled. Often, even if it is coded appropriately (ie, separately), the first encounter is included in the package payment. ACOG attempted to clarify this situation last October, when it observed, “If a patient presents with signs or symptoms of pregnancy and the patient is there to confirm pregnancy, this visit may be reported with the appropriate level of E/M services code. However, if the OB record is initiated at this visit, then the visit becomes part of the global OB package and is not billed separately.” In fact, the visit becomes part of the global OB package whenever the OB record is started at this time, even if the physician is confirming a pregnancy diagnosed by another source.

Services that are often billed separately but considered inclusive by many payers:

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