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The Tricky Game of Payer Edits to Deny Insurance Payments to Providers

The Tricky Game of Payer Edits to Deny Insurance Payments to Providers

Medical billing needs to be completed for each medical practice and the revenue cycle management process requires training, specialized skills, time and focus. Most physicians and office managers have multiple duties per day to manage that provide higher value to their practice than chasing down medical claims. High value activities for Medical Offices include strong patient care, management of front desk team and nurses/Medical assistants and other activities that lead to adding new patients to the practice.

There are many articles related to managing the routine reasons for medical claim denials. These reasons include the front desk team making mistakes or providing misinformation (e.g. the front desk team does not check eligibility consistently), mistake on charge entry or diagnosis codes by providers, credentialing, etc. One aspect of denial management that can be complicated is managing unique payer edits established to deny appropriate medical claims. Each insurance company has their own rules and edits on which CPT codes are paid. With ICD10, software and strong software programmers, Health plans have more ways to deny legitimate medical claims. Each quarter there is at least one payer that changes their rules so that routine medical claims get denied. Usually, a strong team first identifies a change in payer edits when a denied claim is identified and researched. The Payer usually does not make an obvious announcement (usually the information is buried on an insurance company policy site or bulletin that even routine readers of that payers information have a hard time identifying). One reason that payers go through this effort is that denying claims makes more money for the health plan. As much as over 65% of denied claims are not followed up by the billing company or medical biller. This is one of the reasons why many practices have uncaptured revenue. A way to improve the revenue for a practice is to identify a focused Medical Billing company that has proven processes and systems in place to manage through these inappropriate edits.

Example of a payer edit change: One of the managed Medicaid plans changed the requirements for paying for all well visits from submitting the well visit code (e.g. 99392) to requiring both the well visit code, an EPSDT Modifier and certain diagnosis codes are on each claim. The managed Medicaid plan made this change in their payer edit system. The new edits they provide are unique to their plan and require a billing team to identify the issue, identify how to correct the claim and make changes to their billing process. To make this correction to the revenue cycle process requires extra attention to detail beyond what many billing companies are able to manage.

The difference between a good and great medical billing approach is the processes and systems developed as well as consistent execution of claims management by the account manager for the account.