Most Outrageous Rejected Medical Claim
By: LYNNE JETER
Pediatric Patient Questioned about Worker's CompensationBecause basic demographics are a rule of thumb in medical billing – patient's name, address and date of birth at a minimum – it's easy to understand why a pediatric practice would be outraged by having claims on a patient consistently denied because more information was needed about the availability of worker's compensation! "Wasn't the date of birth provided on the HCFA sufficient data to mitigate this inquisition?" asked Stacey Wade of Vantage Pointe Medical Business Solutions in Orlando, adding that gender-related procedures also tend to be problematic for many practices. "Why is it that gender-specific CPT codes often get denied or pended even though the patient's sex is clearly indicated on the HCFA? Occasionally, these denials require submission of medical records, including statements of medical necessity for the services performed, and if the appropriate terminology isn't used to meet the insurance company's 'standard guidelines,' the claim may be subjected to a lengthy appeals process," said Wade. "So, are these denials a delay tactic from the insurance or is there really a problem?" Wade suggested several ways to get to the root of the problem: - Start by checking the patient demographics in your system. It's possible that a data entry error has occurred within your practice, in which case, educating the staff member is an easy fix. "I find this is often the case when practices hire a new employee who isn't familiar with the office's medical software and/or claims requirements," she said.
- Once the data is determined to be correct, research the problem to see if it involves multiple insurance carriers or a single carrier. If the problem is isolated to one carrier, it is possible the denials are a result of a glitch in the insurance carrier's claims adjudication system. "If the problem is widespread, it could be that data is not transmitting correctly from your system to your claims clearinghouse," she said, "or possibly from the clearinghouse to the insurance carrier."
- Either way, the next step involves contacting the claims supervisor and finding out if the data is missing completely, or was submitted in the wrong format (such as the date of birth appearing in the wrong field when the transmission is received), or if there is a problem in the claim adjudication process. "From there, you may need to follow up with your software vendor, claims clearinghouse, or provider representative," said Wade, "and sometimes all three!"
- Making internal corrections to the data may be as simple as changing a data field. Sometimes, it can require more in-depth work. Providers often get frustrated having to spend time and money on an internal change and note that the insurance should have their software conform to the standard format. "This is a very reasonable complaint and most insurance carriers do accept data in the same format," said Wade, "but in the situation where an insurance carrier has a unique requirement, it's generally easier to adjust your software or data entry process rather than to fight the company and wait on them to fix their glitch. This can lead to a critical delay of revenue."
- If, however, your inquiry with the claims supervisor reveals there is no problem with the claim and you truly believe the denials are a tactic to delay payment, talk to your provider representative immediately about the problem. Document your conversation and any actions promised or taken by the representative.
- If you continue to receive denials, the next step is to file a complaint with the Department of Insurance (DOI). Occasionally, the provider representative is the proverbial "low man on the totem pole" and truly has no authority to correct the problem. However, writing a letter to the DOI and sending a "cc" to your provider representative will often incite some action from upper management, often before the DOI even gets involved.
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