Medical Billing Expert

Two of the most significant problems in a medical claims process that can have a profound impact on a  practice are, denied claims and claims re-submission. The extra cost and effort invested in the investigation process can slow down things. While it may be a very common affair, having to deal with it frequently can be quite frustrating and sapping for your business.  Only a well-developed and robust game plan can help you keep denials under control. In this blog we talk in details about the game plan.

Your Denial Management Process is As Good as Your Denial Management Team

It all begins with having the right team. A great team will help you design the right plan and execute it perfectly. So build a team with grizzle-haired people. They know and understand the payor rules  and can ask the claims examiner the right questions. Besides looking into the denied charge, they can help you consistently analyze and improve the process that can go a long way in keeping denials under check.

Your Team Must

  • Know the Inside Out of Payor Rules
  • Ask the Right Questions to the Claims Examiner
  • Review the Billing Record Time and Again

What Your Game Plan Must Encompass

Non-Covered Denials

For these denials, your plan must encompass a detailed review of the CPT code billed, service covered and diagnosis code. The review process must look for wrong codes that may have got documented inadvertently. For instance, if a payor doesn’t cover a particular diagnosis code, review it for errors. If the wrong diagnosis was documented you can always bill for a corrected claim. And if the patient’s insurance does not cover a treatment then you need to make sure to bill the patient directly for the service.


  • Do not change the documentation after filing the original claim
  • Review CPT code for mistakes, and bill a corrected claim

Claims That Need More Information

When it comes to injury-related claims, make sure to provide information regarding the cause of the injury. Provide details of the accident through accurate diagnosis coding. For accident related to students, provide proof of the victim being a full-time student. If you are using unlisted codes, back it up with operative note documentation.

Need for Medical Necessity

Before submitting some claims see if the service was necessary? Was it a cosmetic procedure? Was there a cheaper alternative? Sometimes the service may be medically necessary but the frequency of medical billing may lead to a denial.

Diabetics are permitted to check HgA1C every 90 days. A test before 90 days of a prior test can lead to a denial. But if the test is carried out before 90 days on the advice of the physician it amounts to a medical necessity and warrants a submission. 

Patient Eligibility

Although more of a patient issue, failing to understand the eligibility requirements of the patient can still hurt you. Therefore, your plan must include proper scanning of patient eligibility and letting the patient know upfront that their insurance plan does not cover the proposed treatment.

Bundling it Right

In case of denials due to bundling issues, check the NCCI tables. If they show your code combination does not have a bundling issue, send an appeal for reconsideration. If the combination can be billed with an appropriate modifier, determine it and resubmit the claim as a corrected claim.

Have a Well-Defined Process to Appeal a Denial

  • Every redetermination must be completed within 120 days of receiving confirmation of a denied claim.
  • Use the services of a qualified MAC (Medical Appeals Council) contractor who was not a part of the earlier determination in the fresh process of filing for claims.
  • After initiating a redetermination process get it addressed by an administrative law judge within 60 days, followed by the approval of MAC.
  • Get the judicial review of the appeal in a US district court within 60 days following the approval by the MAC.
  • While having a game plan is important it is also important to carry out regular analysis of the game plan. As a medical practice, seek facts by analyzing data regularly and implement changes in the process. This can go a long way in visualizing denial issues and crafting the right denial prevention strategies.


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