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Five Tips for Avoiding Claim Denials

We’ve all heard the saying, ‘if you didn’t document it, it didn’t happen’. These are the famous words I hear every day from payers and insurance companies. Historically, insurance companies have saved themselves millions of dollars every year by denying claims – claims that should have been paid. But, by simply documenting accurate and timely information for each, you can start to collect what you are owed, successfully appeal denials and hopefully work towards avoiding them in the first place.  

What else can you do? See my top tips for avoiding denials below.

1. Master the online benefit verification process.

We find more and more often that insurance companies are requiring online benefit verification, which in the physical therapy industry can be very tricky. Most payer websites don’t call out specific services, even when benefits vary widely between those services. For instance, insurance companies now have to pay for well-child visits but when you use an online tool for verification it is rarely spelled out that copayments are waived for those services.

The same is true for physical therapy. Most payer’s websites are not designed to factor in the services being performed when you submit online benefit verification info. By requiring online benefit verification, you run the risk of giving patients erroneous information. While payers are moving to online only services for providers, they will still speak with members about benefits so we highly encourage providers to have their patients contact their insurance company to ensure the information that the patient gets aligns with the online information obtained by the practice.

2. Keep a close eye on benefit maximums.

Benefit maximums can also be difficult to obtain through on line verifications and is one of the leading denials that we see, especially later in the year. Keeping close watch on visit limits and having those discussions with patients who are still in need of therapy after their benefits have been exhausted and planning for that can often keep a patient financially on board with the outlined plan of care. There is often a broad gap between benefit limitations and the plan of care outlined for a particular patient.

3. Remain up to date on authorizations.

While you want to stay ahead of authorization requirements, be aware that payers will often consider the previous authorization exhausted, even when visits remain unused, once you request a new authorization. Understanding what your new authorization request does to unused visits on a previous authorization can spare you having claim denials with these payers.

4. Stay current on Medicaid requirements.

New Medicaid requirements are leading to denials and most certainly delays in reimbursement. The CMS has changed requirements for most of our Medicaid payers and now your referring physician is required to be contracted with the payer. In addition to this new requirement, submitted claims are now required to identify the referring provider along with their National Provider ID (NPI) on the submitted claims.

While in most cases these requirements are met, cases are not always set up to identify the correct referring provider. For instance, your primary care physician (PCP) refers you to a specialist, who then refers you to a PT. If you use the specialist in your case information, that claim is likely to be denied by the payer since according to the payer record, your referrer was your PCP and not specialist. Understanding this will ensure you submit cleaner claims.

5. Keep consistent information when credentialing.

Claim denials can stem from something as simple as not using consistent information when credentialing. Here at Clinicient, we are seeing increasing numbers of claims being denied due to the payer information not matching what is being submitted on their claims. Inconsistent taxonomy codes is a denial that we are seeing on the rise – especially when a therapist has multiple contracts with a payer, like PT and OT, or PT and acupuncture. The use of taxonomy codes is somewhat new and I don’t think any of us truly recognized the implications of assigning a taxonomy code that is slightly different from what your payers have on record for you. By using the same taxonomy code for all contracts you can save yourself a giant headache, as well as the lengthy process of having to update your contracts with your payers.

Looking for more info? Check out more information around collecting faster, fuller payments here.

One thought on “Five Tips for Avoiding Claim Denials

  1. When clinic is onboarding, its important that they have an owner who becomes clinicient expert, AND still have a billing liason in house who understands billing, so can ensure smooth transition in billing. We learned the hard way a bit on that.

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