Coding and Billing

Don’t Give Up: How to Retrieve Payment for Denied Claims

By Eric Botts, OD

When claims are denied, apply an effective strategy to retrieve payments. You don’t have to immediately consider the reimbursement a loss. Here’s the how-to.

Successful filing of your insurance claims guarantees the following:
•    Increased exam revenue
•    Decreased account receivables
•    Improved staff productivity

Unfortunately, not every claim is always submitted accurately, therefore, you have to learn how to resubmit denied claims or hire a billing service to submit your claims for you. In my experience, 5 percent of all claims result in 95 percent of all the denials my staff deals with. To minimize my denied claims, I implemented the following steps:

•    Properly credentialed all doctors with correct NPI and Tax ID numbers
•    Trained my billing staff how to correctly submit claims
•    Added electronic health records to my practice to improve efficiency
•    Instructed my doctors how to properly code their exams

These steps significantly lowered my denial rate which quickly resulted in less frustration and headaches for both staff and doctors. However denied claims will still occur and must be researched and resubmitted to prevent loss of income. Researching denied claims can be time consuming but if resubmitted correctly will pay for themselves.
A denied claim typically is reported on the explanation of benefits (EOB) that you receive. It will include a claim adjustment reason code (CARC) that briefly explains the reason for denial. Following are a few examples of CARC:
•    PR- Patient responsibility. Amount that may be billed to patient or other payer.
•    CO- Contractual Obligation. Amount for which the provider is financially liable. The patient may not be billed for this amount.
•    PR-16- Claim/service lacks information which is needed for adjudication.
•    PR-22- Payment adjusted because this care may be paid by another payer per coordination of benefits.
•    CO-50- These are non-covered services because it is not deemed a “medical necessity” by the payer.
•    PR-96- Non-covered charge(s).
•    PR-204- This service is not covered by the patient’s current benefit plan.
•    OA-18- Duplicate claim/service.
•    OA-109- Claim not covered by the payer/contractor. You must send claim to correct payer/contractor.
•    CO-97- The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
•    CO-4- The procedure code is inconsistent with the modifier and/or a required modifier is missing.

This is a short list of the more common CARC you may encounter on denied claims. When you receive an EOB with one of these CARC then you must figure out how to correctly resubmit the claim. Here are a few examples of CARC along with the mistakes that they describe.
•    PR-16- Doctor credentialing information previously submitted to carrier does not agree with doctor NPI or Tax ID submitted on the claim.
•    Corrective action: You must ensure credentialing information is correct for doctor including individual and group (if necessary) NPI, as well as Tax ID, location address and billing address.
•    OA-109- Medicare claim denied because patient has a Medicare advantage plan that is primary payer.
•    Corrective action: Resubmit claim to Medicare advantage plan
•    CO-4- Office visit 99214 is denied when performed on same day as punctal plug insertion 68761.
•    Corrective action: Resubmit 99214 with -25 modifier.

Denied claims can become very frustrating because coding and billing rules are constantly updated. Staying on top of all these changes can be difficult, however if 5 percent of your claims are not reimbursed due to errors the cost to a busy practice can equal $15,000 or more. If you do not have a well-trained billing specialist to research and resubmit your claims then you may want to consider enlisting a billing service to submit all of your claims so you don’t leave any exam fees on the table.

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Eric Botts, OD, is founder and president of OBC Billing Specialists, and president of InnovativeEyes, in Macomb, IL. To contact him:

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