The first question in our “Ask Audrey" series, where Physicians Practice readers send in their practice management queries for guidance, involves remittance codes, and how to compare them with industry benchmarks.
Is there a list of remit codes industry wide that are categorized as denials? To be more specific, the problem I am currently having is comparing the initial denial rates that we have on our professional billing side to industry benchmarks. Everywhere I look for reference I see that benchmarks for denials should be less than 5 percent for best performers and between 5 percent to 10 percent for average performers, but I can’t find how denials are being calculated. What remit codes are used to measure that benchmark?
Mamoon, New York
Special thanks to Mamoon for submitting a great question. In order to answer Mamoon’s question in the best manner possible, I called on billing expert Manny Oliverez, CPC, of Capture Billing. He has more than 20 years of experience in healthcare, and started his nationwide billing service in 2004.
According to Oliverez, benchmarks are calculated pretty simply, but only with the data that is reported. “Benchmarks are number of claims divided by the number of denials,” said Oliverez, who noted that it has been reported that about 35 percent of providers don’t even appeal their claims, which is a significant number of providers whose denials are not calculated in the 5 percent to 10 percent benchmark (not to mention a significant amount of lost revenue!).
The short answer to the question is that there are no standardized remit codes between insurance carriers. Oliverez said that he finds that the consistency of standardized code is lacking.
“We group our own codes in our software using the specific categories,” said Oliverez. “You can also go to your insurance carriers’ websites and download their specific codes, but they don’t all use the same codes.”
The categories in your software he recommends are:
• Coordination of benefits
• Terminated Insurance
• Dependent not covered
• Incorrect place of service
• CLIA Modifier needed
• Modifier needed
• Not a covered service
• Timely filing
You may have some additional categories for your particular practice.
There may be hope for future standardized remit codes between carriers, although Oliverez said he has heard that rumor for about the last several years.
Do you have a question about a practice management issue in your clinic? Would you like some ideas on how to fix a problem? Submit your anonymous questions to Ask Audrey and practice management expert Audrey “Christie” McLaughlin, RN, will answer them in a future Practice Notes blog.