RemitDATA's chief operating officer, Brian Fugere, explores the most common unexpected denials at medical practices nationwide, with a focus on pediatrics. Use the "Next" button to advance the slides and read Fugere's commentary on the latest claims denial trends in medicine.
The data represented was collected from electronic remittance claim service lines between Jan 1, 2014, and Jan. 31, 2014.
In the summary of activity for January 2014, the top five denied procedures across all specialties should not be a surprise if you read the end-of-the-year recap last month, according to RemitDATA's chief operating officer Brian Fugere. Once again, E&M office visit procedures (99213 and 99214), hospital visit (99232), and seasonal procedures are featured prominently. As the flu and cold season continues, routine blood draws (36415) and specimen transfer (99000) worked their way into the top five.
From a denial reason perspective, the top five denied reason codes again reflect potential process issues that are affecting payment to physicians. Most of the top five reason codes (including duplicate claim/service; claim lacks information or has errors; and time limit expiration) revolve around adherence to payer rules when forming and submitting a claim. These process-related issues can be relatively easy to solve within a practice. The key is additional training and enhanced compliance management.
Focusing on pediatrics for this month, we note that two of the top five denied codes are related to office visits (99213 and 99214). The remainder of codes might indicate an increased number of college-age children visiting their physicians during their winter break.
From a denial reason perspective, all of the top five reason codes will look familiar - they again indicate a lack of compliance with payer rules or eligibility issues. These are relatively easy to fix with additional training and enhanced compliance management.
Remember, every patient visit requires an E&M code, so these are the most common codes used. Overuse of higher level E&M codes can be a red flag when there are high denials, as seen by the presence of 99213 from the top 5 lists. Red flags for denials should also be top of mind for physicians and practice administrators as they can be easily remedied.
Don't throw money away at your medical practice, which is what happens when you ignore claim denials. The cost to work a denial is estimated at $25 to $40 per claim, so reducing denials makes an impact on the front and back end of your practice. Practices should analyze their denials closely, put practices in place to proactively address issues, and also understand how their performance compares to their peers so they have benchmarks.
