If you read last month's Most Outrageous Rejected Medical Claim column about CPT code 99213 being "invalid on the date of service," you would have to concur that an egregious mistake was made on the part of the insurance carrier. While the mistake was easy to decipher, some insurance rejection mistakes are not so conspicuous, as one of Stacey Wade's clients recently discovered. Wade, of Vantage Pointe Medical Business Solutions, explained: "The company received several non-payment EOBs from one particular carrier that stated, "Fax Facility Medicare # to..." and provided the fax number for customer service. The billing representative complied with the request and appropriately followed-up with a phone call to make sure the claims were being reprocessed. She was advised the claims had indeed been sent for review. However, upon receipt of the next EOB, the claim was denied again with the same rejection reason." Next, the claims supervisor was consulted to escalate reprocessing. "Medicare numbers were reviewed and confirmed to be correct in their system, but after yet a third denial for the same reason, the provider relations representative was contacted for resolution," she said. "The provider relations representative went through the same process of verifying all the data to be correct and sent the claims through the system--only to be rejected again!" At that point, the provider's billing representative pulled out the insurance contract to determine the next course of action. That's when she discovered the provider was not contracted for the Medicare product line with that insurance carrier. To add insult to injury, during the time spent talking with the claims and provider relations departments, no one from the insurance company recognized the true issue or the meaning of the rejection code that was being used, explained Wade. "After four months of going back and forth with the insurance company, all the while adding new claims to this problem list," she said, "it boiled down to a contracting issue, which could've been caught and resolved much quicker if the rejection had been a little more clear, such as, 'provider not contracted.'" Ultimately, it was the provider's responsibility to know which programs were included in the contract, but for many, the alphabet soup of commercial product lines and Medicare options is often very confusing. Keeping up with constant changes is a daunting task, noted Wade. "To avoid incurring a mountain of non-covered account receivables, it's imperative that providers designate someone to maintain a quick reference guide for participation, not just by carrier, but specifically the products for each carrier," said Wade. "In this example, even the on-line benefit verification gave no indication that this was a new product line or that the provider was non-participating with this patient's particular plan." Finally, Wade pointed out, it's important to remember that the claims adjudicator or software adjudication system used by insurance carriers usually has a generic list of rejection codes that cover most issues. "But it seems that when there's not a direct answer for the rejection, they simply choose a similar reason that may or may not indicate the bottom line," she said. "Sometimes, we're left to read between the lines!"