Medical Billing Blog

Health Care Billing: Big Denials/Easy Fixes

  

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Denials continue to plague practices from federal and commercial payers.  Analyzing and trending denials are important for two reasons:

1. Preventing the denial
2. Appropriately working the denial for fast payment 

Obviously, attention must be paid to preventing the denial.  It is usually an education issue.  To the extent providers, front-end staff, billing personnel, and coders are educated about requirements and new changes, to that extent denials can be prevented.  Education of staff pays for itself in first time paid claims.

 Many facilities are seeing a dramatic increase in OHI (other health insurance) denials from Medicare and Medicaid.  The reason for this is the increasing presence of HMO/Advantage plans offered by MCR/MCD intermediaries.

 For existing patients who have MCR B coverage, this problem is exacerbated by front end who typically say to patients, "do you still have MCR B?" and patients answer..., "yes, I do" and are asked to see their MCR B card.  Then what happens is they also show their HMO/advantage card  which is then loaded as a secondary plan.  The HMO/advantage plan is primary and hence the OHI denial. 

A simple change in the script front-end personnel are using when asking MCR patients about coverage can avert this denial.  Front-end personnel must be taught how to look at insurance cards and translate information provided.  They can use "cheat sheets" that describe the differences,  they can ask questions to clarify coverage, they can call the billing office to ensure correct coverage is being loaded in proper sequence.  Each organization must address this issue and look at work-flow, education of staff and education of patients to ensure proper payment the first time a claim is filed.