13 Reasons a Claim is Denied
1). A duplicate claim was submitted when a practice hasn’t received reimbursement.
2). The patient isn’t eligible for services because their health plan coverage ended, and the patient hasn’t shown proof of new insurance.
3). The patient hasn’t met his/her deductible for the year.
4). Some services are bundled. For example, laboratory profiles with multiple tests don’t qualify for separate reimbursements, or an all-encompassing rate covers the minor procedures and the pre- and post- procedure visits. The provider receives one combined payment.
5). The benefit has been exceeded, such as the maximum allowed number of physical therapy visits covered by the health plan within a calendar year.
6). The claim form is missing a modifier, or modifier(s) are invalid for the procedure code (as in the case of bilateral codes billed on both sides).
7). An inconsistent place of service is marked on the claim form, such as an impatient procedure billed in an outpatient setting.
8). A particular service isn’t covered under the plan’s benefits, or there appears to be a lack of medical necessity. In another example, there could be a mismatch between the actual diagnosis and the service performed.
9). The claim is deficient in certain information. It may be missing prior authorization or the effective period within which the pre-approved service must be provided for the reimbursement to occur.
10). There is a coding data error with mismatched totals or mutually exclusive codes.
11). It may be necessary to coordinate benefits when dual coverage issues arise, such as with secondary insurance or worker’s compensation.
12). The filing deadline has passed. If a claim isn’t submitted to the insurer within the permitted time frame, it is likely to be rejected. The limit to file can be as short as 90 days from the date of service.
13). Errors or typos were made while collecting pertinent information from the patient or during the data entry process for a claim.
More on DEA Training
Please click on this link “DEA Registered-Practioners” to read the Letter from the Drug Enforcement Administration (DEA).
Pay close attention to “Group 2”. There are other ways to satisfy the training requirement.
Additional Links:
New Requirement – DEA Registered Practioners
HEADS UP!
All practitioners registered with the Drug Enforcement Agency (DEA) will be responsible for fulfilling a one-time, eight-hour training requirement on the treatment or management of patients with opioid or other substance use disorders. Practitioners need to satisfy this requirement before their initial or next scheduled DEA registration submission on or after June 27, 2023.
There are multiple ways that a practitioner may satisfy this new requirement — the DEA sent a letter outlining these options and providing a list of accredited groups that may provide trainings. The Substance Abuse and Mental Health Services Administration (SAMSHA) has additional information about frequently asked questions. MGMA Government Affairs will discuss this policy in more detail during our upcoming mid-year policy update webinar.
PLEASE CLICK ON THE LINKS IN THE ABOVE PARAGRAGH FOR MORE INFORMATION.
Difficult Patients
Seems We All Have THAT One.
It’s confusing to refer to a patient as “difficult.”
Difficult?
Are we talking Multiple Comorbidities that are tough to manage?
Maybe they question your medical judgement?
Is it that one that derails your whole day, by telling you their life story?
Or is it just possible they were just born: Angry, Frustrated, and noncompliant?
Whatever the reason for your “difficult” patient, click on the button to view Amanda Hill, JD’s article in Physicians Practice to get some strategies to help deal
How to Better Manage Incoming Calls
Seven easy ways to expedite the incoming phone call process.
1). Simplify, shorten, and reorder the greeting.
2). Reduce the number of rings before rolling to voice mail.
3). Tell patients when to expect action or a call back (this is crucial).
4). Equip staff to handle calls effectively.
5). Secure a portal for patient communication.
6). Provide patients with educational materials they can reference at their leisure.
7). Provide patients with a summary of the visit.
To gain a better understanding of root cause please read this short informative article from Physicians Practice. It can be a great revamping and or training tool.
Renewed Form for ABN
The ABN, Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal. The use of the renewed form with the expiration date of 01/31/2026 will be MANDATORY on 6/30/23.
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers to Original Medicare (fee for service – FFS) beneficiaries in situations where Medicare payment is expected to be denied.
The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances
TMA Welcomed Unanimous Passage of House Bill 3359.
A major win for medicine in that it codifies the state’s network adequacy rules by putting them into statute and strengthens their enforcement by the Texas Department of Insurance (TDI).
“HB 3359 restricts insurers from making unilateral contract changes and tackles the problematic waiver process which leaves patients unprotected and in the dark.”
TMA now looks to the rulemaking process. TDI has indicated it likely will rewrite the state network adequacy rules impacted by HB 3359
Aetna Claim and Code Review Program
This update applies to Aetna’s Commercial, Medicare and Student Health members.
Beginning September 1, 2023, you may see new claim edits. These are part of our CCRP. These edits support our continuing effort to process claims accurately for our commercial, Medicare and Student Health members. You can view these edits on our Availity provider portal.*
For coding changes, go to Aetna Payer Space > Resources > Expanded Claim Edits
With the exception of Student Health, you’ll also have access to our code edit lookup tools. To find out if our new claim edits will apply to your claim, log in to the Availity provider portal. You’ll need to know your Aetna® provider ID number (PIN) to access our code edit lookup tools
Aetna on Pre-certs
Submitting Precertification Request
Be sure to submit precertification requests at least two weeks in advance. To save time, request precertification online. Doing so is fast, secure and simple.
You can submit most requests online through our Availity provider portal.* Or you can use your practice’s Electronic Medical Record (EMR) system if it’s set up for electronic precertification requests. Use our “Search by CPT® code” search function on our precertification lists page to find out if the code requires precertification.**
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