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Since commercial and Medicare payers keep detailed profiles of questionable claims submitted by each provider it deals with, a physician practice can use this information to spot patterns and weaknesses in its own coding and billing operations. One of the easiest and best ways to start accumulating this information is by tracking the reasons for denial cited on the Remittance Advice Notice received from your Medicare contractor. Based on data from the Health Care Financing Administration, some of the leading reasons for denying claims are:
• Poorly documented or outdated diagnostic codes. To avoid mistakes, make sure your diagnosis codes have been both updated, for physicians and in your computer systems. Stress that they need to be as complete and specific as possible. The more detail and documentation you have to backup your coding choices, the less likely your claims will be denied.
If you have had problems with frequent denials based on questions of medical necessity, for instance, you may want to check with the carrier and get its latest policies regarding coding for those particular conditions or services. Also get a list of the medical protocols it considers appropriate for how these services should be performed or what it feels are legitimate alternative treatments for these conditions.
• Medicare is this beneficiary’s secondary payer. One of Medicare’s new policing priorities when it comes to processing claims is to ensure it does not get struck paying the bill for patients who should have been covered by private insurance. This makes it important that you have patients update their information, including their most recent employment or retirement status and any alternative coverage each time they come in for a visit.
Tip: To avoid possible denials, consider asking patients to call Medicare and update their files themselves.
• Duplicative claims. If you are have a significant number of claims returned because they were duplicates of bills already submitted or currently being processed, check your computer software and billing system for possible bugs. If no problems are found there, you may have simply resubmitted too quickly a bill that needed additional information.
• Incomplete or inaccurate physician ID and referral numbers. A simple cross-check of your claims processing software will validate whether the various physician identification and referral numbers required by Medicare have been correctly entered for each physician in your practice.
• Referrals. Well-designed forms and office procedures will help eliminate any referral-related payment problems.
Tip: Patient registration forms should have a space to list the physician who referred them to the practice. The same is true for charge slips so the treating physician has enough room to clearly write to whom they referred a patient. This information should be automatically logged into the patient’s computer file, with a cross-check to ensure the data are complete and included on the claim.