Much attention and dedicated work have been devoted toward clinical documentation improvement and accurate, specific coding. Clearly, those are of great importance. However, I want to address the physician Part B insurance denials that have nothing to do with how good the clinical documentation is and how accurate the coding is on the claims. Common frustrations that we see every day are myriad.
Consider requests for prepayment review for a service with an allowable billing of $8.90. It will cost two or three times that much to gather reports, orders, and supporting medical records. Is that really a reasonable use of anyone’s time?
Incorrect or delayed payor updates and edits as new codes are released and new policies are published can cause claim denials for months. In a few cases, the payor will reprocess the incorrectly denied claims. However, in many cases, it is up to the provider to monitor and resubmit the claims to obtain legitimate payment, incorrectly denied.
Radiologists are held accountable for what the referring providers document to support the medical necessity of the diagnostic testing they order. Not only is it a tremendous burden to have to obtain that documentation, but if the referring physician documented poorly, it is the radiologist’s payment that is recouped.
Some of the Centers for Medicare & Medicaid Services (CMS) medically unlikely edits (MUE) for a date of service are not consistent with standards of practice for some specialty services. Rather than paying at least the number allowed per day and requiring appeals for any services exceeding the total allowed, all units of service are denied. Yet, again, appeals are required, which greatly increases work and cost for the provider (and presumably for the MAC, or Medicare Administrative Contractor).
Entities that pre-authorize services may not have correct payor information. For example, a common problem is authorization of a specific CPT. However, the payor may actually require a HCPCS code for the service. The authorized service is denied, and when the claim is corrected to meet the payor coding requirement, it is denied again as being unauthorized. It’s a vicious circle that withholds legitimate payment for legitimate services.
More and more payors are not accepting calls from revenue cycle companies or physician billing representatives. Not all issues can be successfully resolved via email, so a large roadblock can exist. When calls are accepted, our experience is that the average hold time is 20 minutes. In addition, many insurance companies limit the number of questions that can be asked on a call. This issue is greatly exacerbated by the large volume of remittance explanations (CARC/RARC) that are so nebulous or completely inaccurate that the reason for the denial cannot be ascertained. The time and cost to even attempt to get an answer is frankly, absurd.
I think the physician community and the billing industry as a whole would like to see insurance companies held to the same rigorous mandates for transparency, accuracy, timeliness, and accountability as the rest of us.