Solved! Denied Again

March 1, 2009

What do you do when your claims keep getting denied by the same payer, seemingly without explanation?


I have a big problem with Medicare. None of my claims are getting paid. I follow all their advice. I even called and asked if a few of the codes I’m using are the right ones. They said they were but I’m still not getting paid. Can you help?

Whenever you get a denial - or just a plain no answer on a claim - you need to step back and do a little diagnostic work.

Here’s some logic to follow:

None of your Medicare claims get paid?

Then the issue is probably not a wrong code here or there. It probably has more to do with your participation status or how you are submitting claims. Otherwise, just some claims would be denied.

Do you get back a denial? Then at least you know Medicare is getting the claim. If you don’t ever hear anything back, then look at where the claims are being sent. They may not be getting to the payer at all. Ideally, you submit them electronically, and a clearinghouse can help you remedy any problems. If you do get a denial, it should have a denial code and explanation, no matter how confusing that explanation is. What does it say? If there are issues with your participation status or ID number, it should say so there.

Now, what if you do end up with a handful of claims that are denied by a payer? It’s important not to just throw up your hands and assume “they just won’t pay for that.” Again, do a little investigating, starting with the denial codes and explanations.

And be logical about it. Ask someone in the billing office to track (or better yet, automate such tracking) all the denials that come in and why they happened. There’s a denial tracking worksheet in the Tools area of PhysiciansPractice.com you can use for this purpose.

Over the course of a few weeks, you’ll get a much better sense of what’s causing denials in your practice. Then, you can focus on the biggest problems and fix them.

Too often, the problems start in one’s own office: Late filing, member not eligible with payer, duplicate filings - these are problems you can fix yourself. If there are problem areas in your practice, ramp up your eligibility checks and review the processes your front-desk people follow at check in. The front desk can have a significant impact on your claims getting paid or denied, as that is where member information is largely entered. It’ll help if they can see how big a problem there is so they can track how their efforts improve the situation.

If that’s not the problem, then double-check whether you are using the codes correctly yourself. Thoroughly read the CPT book for the definitions of the codes under question. Are some designated -51 modifiers exempt or do they have other restrictions, by definition that are causing the problems?

If not, the next place to look is at the prohibitions set out by the Correct Coding Initiative (CCI). Basically, CCI lists pairs of codes that you can’t use together either because one code is always considered part of another (if you amputate the leg, you always amputate the foot, too) or because they almost never happen together (a Pap smear and prostate check). CCI calls them “column 1/column 2” and “mutually exclusive edits.” You can get a full list of them for free. Most claim-scrubbing software also checks for them. Claim scrubbers search electronic claims for obvious errors before they get sent out. You can find a list of some in the Physicians Practice online Buyers Guide. Look under coding products. Also ask your clearinghouse and practice management software vendor what they offer.

If the coding looks right according to CPT and CCI, then likely payer policy is causing the denials. To find out, you can call them or search their sites, which are increasingly robust. If the payer has a policy not to pay for some service you are doing, you sure can call the medical director and fight about it, but pick your battles.

The key point here is to act like a detective when it comes to unpaid claims. Work logically through a process to see where the problem lies. You don’t need to aimlessly call around or just hope for the best - eventually. Taking the time to figure it out yourself will be worth it.

Pamela L. Moore is director of content and strategy for Physicians Practice. She can be reached at pam.moore@cmpmedica.com.

This article originally appeared in the March 2009 issue of Physicians Practice.