 | Shoreline |
Denial codes can be a significant obstacle to successful reimbursement, but they do not have to stand in the way of practice revenue. There are proactive steps that you can take in order to decrease denials and speed up payment.
Before we dive in, let’s define a “coding denial.” A denied claim is a claim that made it through the adjudication system - it’s been received and processed by the insurance or third-party payer. However, the healthcare provider deemed the claim unpayable for the services rendered.
Most times, payers will send you an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) that explains why the claim was denied. Even though a payer denies a claim, that doesn’t mean it’s not payable, and you can appeal the claim. However, before re-submitting the claim, you must determine why the claim was denied and correct the errors.
Following are common denial remark codes and suggestions on how to rectify them:
This specific code occurs when expenses were incurred after the patient’s coverage was terminated, meaning the practice provided health care services to a patient after their insurance policy’s termination.
Your main goal should be to prevent these types of denials because they’re hard to fight. This means verifying your patients’ insurance benefits before you render services so your office is alerted to your patient’s insurance coverage status. The front office staff should be verifying insurance for every visit. This helps you either get the most up-to-date insurance information or determine whether the individual is a self-pay patient, so you can collect payment at the time of service.
When a medical practice encounters a denial remark code that references "expenses incurred during a lapse in coverage", it is referring to any claim charges made while the patient was suffering from an interruption of their insurance coverage. To rectify this remark code, the medical practice should verify that the patient's insurance is current, and resubmit all claims being denied as a result of this lapse in coverage. It is important that practices stay up to date on insurance verifications, so as to avoid losses due to denials. Staying organized and documenting all patient interaction, helps practices quickly and efficiently identify any issues related to insurance lapses or other denied claims. This allows them to mitigate potential losses and ensure timely payment processing.
If you receive a denial, it means the service is not covered or you have failed to jump through one of the many hoops insurers use to process and pay out claims. Some of the most common issues that arise are: claims were not filed in a timely manner, the claim might have already been paid and not noted, the claim does not justify the necessity of the service provided, or the provider was not certified to provide that specific service - at that time or ever.
When filing claims, it’s important to know what is and is not covered by the payer. When familiar with the payer’s coverage and payment terms, offices can make decisions about the appropriate treatments and services before providing them.
Secondary payment during medical billing is a form of coverage that applies when an individual has more than one health insurance policy. In these cases, the secondary payer provides payment on eligible expenses after the primary payer has processed the claim. When a provider is denied a claim under the "secondary payment cannot be considered” code, it indicates that the practice has already received payment from another health plan for the same service. To rectify this situation and potentially get the claim paid, practices must contact the other health plan in order to request reimbursement for any payments already made. In some cases, this can be done even if reimbursement was previously denied by the other plan, so it is always worth trying before considering a claim fully rejected. As such, understanding denial codes is key in successfully billing claims and getting them approved.
Regardless of what type of denial code you face, there are many strategies you can implement to increase your practice's reimbursement. With thoroughness and attention to detail as well as staying up to date on the industry’s best practices surrounding insurance denials, your practice can minimize delays in payments and save valuable revenue. If you have any questions or need help regarding insurance denials, our team of experts at Shoreline Medical Billing is standing by ready to help.
Contact us today so we can start working together to optimize your business success!