- annual preventive exams, which may include a related problem-focused visit and/or related lab tests; and
- global obstetric packages, which may include ultrasounds, nonstress tests, and routine Pap smears.
ACTION PLAN
To manage denials for inclusion, require each payer to outline its rules about bundling for the services you commonly bill. For example, ask the payer to list the services included in the global obstetric package, and get it in writing. Then train yourself and your staff on what’s included—and what’s not.
Have your staff flag denials that can be appealed, and offer to dictate a letter, if necessary, explaining when services you performed were coded and billed appropriately as 2 (or more) distinct services.
2Make preauthorization top priority
Some payers require preauthorization for specific services. A common example is amniocentesis. Ask your billing staff to alert you to any claim denied for lack of preauthorization, precertification, or referral approval. Although appeals of these denials after the fact are often unsuccessful, you should usually make the attempt anyway. For example, if your patient did not provide accurate information about her coverage, you may have unknowingly failed to obtain the necessary authorization or billed the wrong insurance company. Even though it is too late to obtain the authorization after the service is rendered, write an appeal letter for this type of denial. Explain to the payer that the patient failed to disclose the correct insurance coverage; thus, you were not able to follow its rules.
ACTION PLAN
For services you commonly render, make a list of the payers that require authorizations. When the service is ordered, check that list to determine whether preauthorization is necessary. Better yet, summarize those common services and the patient’s benefit coverage in the patient’s paper or electronic chart. If services are denied, consider appealing the decision.
3Stop “duplicate billing” denials
Some claims are denied because the payer concludes it is a duplicate. This may happen if you mistakenly send a claim more than once; at other times, the patient actually had similar services performed, but the payer mistakes them for a single service.
For example, a patient presents with a urinary tract infection (UTI) twice in the same week. You appropriately code your level of service for the encounters, which may be code 99213 in both cases, and attach a diagnosis of UTI. The payer may not spot the different date for the second service, and mistakenly assumes the second is a duplicate.
ACTION PLAN
Put your staff on alert for inappropriate denials based on duplication. Appeal these denials for payment and point out in the appeal that the services were rendered and accurately coded and billed.
Your staff could be a cause of high denial rates. Perhaps they simply resubmit claims without considering the situation, or fail to attach new information to the resubmitted denial to help the payer understand that it is not a duplicate claim. Unfortunately, it is common for unproductive or unknowledgeable staff to simply rebill claims as they work open or denied claims.
Before you rebill a claim, it is important to evaluate the account carefully. Determine the status of an open claim before resubmitting it.
For a denied claim, fix the problem or attach an explanation—instead of making the same mistake twice. If that’s the case, you’ll just get a denial for a duplicate claim, no payment, and more work to do.
Many ObGyn practices are plagued by registration-related errors that translate into claim denials. If the registration process is inaccurate, even by a single keystroke, the claim will be denied. Common registration-related denials include: “subscriber not eligible on the date of service” and “subscriber not identified.”
ACTION PLAN
Be a stickler. Track down staffers who make mistakes and show them what they are doing wrong; otherwise, they’ll just keep making errors. At each patient encounter, or at least every 3 months, verify insurance and eligibility—with both patient and the payer. Use payers’ Web sites to confirm coverage.