Stop denials due to inaccurate info

Work closely with providers

When speaking with a payer representative, verify eligibility first, then move on to more specific details such as service category and codes, recommends John T. Porter Jr., access denial analyst for patient financial services at Scripps Health in San Diego.

“Consider what information is on your billing claim, which is required to determine payment,” says Porter. “If this information is not available, start requesting it from providers as a standard practice.”

When a physician’s office contacts patient access staff to order a procedure, Porter advises obtaining the exact Healthcare Common Procedure Coding System (HCPCS), Current Procedural Terminology (CPT), and International Classification of Diseases (ICD-9) codes that will be on the final order.

“Access staff are not always certified coders and should not be left to interpret or assume what codes will be used by the referring or ordering physician,” he says. “The reason is that every CPT/HCPCS code is correlated with a list of medically justified ICD-9 codes.”

These medically-justified code combinations are contained within an insurance company’s medical coverage policy and vary for every insurance company you contact, says Porter. He recommends these practices to ensure the correct codes are verified for coverage prior to service:

• Request the referring office to include procedure codes, procedure description, diagnosis codes, and diagnosis descriptions.

This step will ensure the codes that are used to verify coverage are the same as the ones used on the claim by certified coders, says Porter.

• Inform providers that the insurance companies require codes to be accurate in order to determine coverage.

“Explaining that you are trying to prevent a claim denial for their patient goes a long way,” says Porter.

• Educate providers that medical policies and the codes involved are constantly being updated.

“What was covered yesterday might not be covered today,” says Porter. “Constant communication and feedback between providers is essential to stay up to date on the ever-changing state of healthcare coverage.”