When a physician provides medical services to a patient, the expectation is that they will receive reimbursement for that service. When the payer issues a denial and requires a claim adjustment, the provider doesn’t receive their payment. Many times these denials can be appealed, depending on the reason for the denial.
Below, the medical billing and coding experts at MEREM Healthcare Solutions have provided five of the most effective responses you should take when handling a claim adjustment.
5 Effective Responses to Common Claim Adjustments
Prove Medical Necessity
Sometimes claims are denied because they have been deemed medically unnecessary. In this case, you may need to submit additional information to prove that the service was medically necessary.
For example, if a person who has lost a lot of weight has surgery to have their excess sagging skin removed, the claim may be denied as cosmetic surgery which isn’t medically necessary. However, if the physician were to provide evidence that the excess skin was causing chaffing and irritation which led to an infection, it then becomes clear that this was a surgery of medical necessity.
What if a Service Isn’t Covered?
If you have a claim denied because the service, such as a weight loss plan, isn’t covered by the payer, don’t adjust the claim. These claims are to be billed to the patient that received the service. If you adjust the claim, then you are providing the service free of charge. The responsible party for a service that isn’t covered is the patient, not the physician.
No Prior Authorization
If you have a claim denied due to not receiving prior authorization, the first thing you need to do is check with the office to make sure they didn’t actually receive prior authorization. If they did, simply add the code and re-file the claim on the CMS 1500 form.
If a prior authorization was not obtained, see if the payer accepts retro-authorizations. They may not, but it never hurts try.
Timely filing denials are a common occurrence when resubmitting a claim that was previously denied. The way to counteract this problem is to be sure that, when you file a corrected claim, you include the payer’s previous claim number that was issued on the denial so that they will see that the original claim was filed in a timely manner and you won’t be denied.
Sometimes when a bilateral procedure is billed on two lines, the payer may incorrectly assume that it is a duplicate. The release of ICD-10, cleared up some of this confusion thanks to the new codes that identify which side of the body a procedure was performed.
Until then, you must resubmit your claim with the correct information and let the payer know that the claim was actually for two separate procedures.
Get Your Claims Adjustments Managed By Medical Billing and Coding Experts!
These examples are just a few of the reasons you could receive a claims adjustment. There are many others including bundling and coding errors.
If you want to take the guesswork out of medical billing, saving your practice or hospital valuable time and money, then turn to MEREM Healthcare Solutions, your team of medical billing and coding experts!
Contact the professionals at MEREM Healthcare Solutions today to learn more about outsourcing medical billing and coding services for your medical practice.