Question for Billing and Coding expert

granddi · ‎03-16-2010

I know a little bit about billing and coding but I'm asking those who are professionals.

When a claim is rejected is the most likely reason:

1. Non-covered sevice

2. Error by dr office in filing/indicating the proceedure code

3. Error by the dr office in filing/indicating the diagnosis code.

4. Proceedure not payable for filed diagnosis code

5. Claim not filed timely

6. Deductable not met

7. Other (clerical eg)

I think sometimes when claims are denied the problem is how the claim was filed. If we call the dr office/insurance co and inquire as to the reason for denial, some will refile and some will say too bad.

I'm over 65 and know that I am eligible for Pap every year due to my history. Last Pap was denied with a new doc. I am certain that IF they had filed the claim correctly the service would be approved. But refiling the claim would be a lot of trouble for the office. I did sign to pay if no pay by insurance. So they got their money and are lazy to help me with claim.

patbz · ‎03-10-2010

@granddi : Years ago DH had a quadruple bypass; when we got the bills, our insurance had denied coverage for the anesthesiologist (I guess he was supposed to bite down on a piece of wood...). Didn't even bother to ask for new code; next bill, we didnt owe for that service.

Mz iMac · ‎07-26-2014

If you have a copy of your bill you can check the code & its meaning on a medical code website.

Also your Medicare EOB will give an explaination for the denial.

"Never argue with a fool. Onlookers may not be able to tell the difference."

deepwaterdotter · ‎03-09-2010

In my experience, it's usually reason no. 4. When I bring it to the provider's attention, it is resubmitted with a code that provides for payment. It may take a while for payment to be made, but it usually happens.

millieshops · ‎03-09-2010

@deepwaterdotterand @granddi I agree with deepwater - there should be an explanation on your Medicare paperwork, but I'd add that when I feel there's been an error, I call the billing office BEFORE I send them money.

I don't know what it's like where you all doctor, but where I do, the office staffs are overwhelmed with computer and paperwork, so I figure it's my money - I'll try again to keep some of it!

Carmie · ‎10-25-2010

I have never been a biller or coder, but I worked 25 years for a health insurance company and know my stuff.

Claims that are applied to the deductible are not denied.

A lot of claims are denied or not processed correctly because they are missing information.

I have found that personally Medicare claim processors don't always process claims correctly and their denials are confusing.

I will spend the day tomorrow on the phone because they denied a tetanus shot my DH had this summer. It was denied as a non covered service.

I know that a rourine tetanus shot is not covered, but the are covered as part of a treatment were an accident occurred. My DH cut his head on our boat.

This same claim for all of the ER services denied before as a Workman's Comp (WC) being primary. My DH had a sprained ankle almost 15 years ago and some some dumb reason that WC issue triggered this claim to deny.

It took me two days on the phone to figure out why this claim denied and I had to call the WC insurance and have them fax Medicare a paper showing the WC issue was closed. Medicare denied receiving the fax and the WC insurance has to resend it.

They paid all of the charges, except the tetanus shot. I will be back on the phone again tomorrow.

IMO, Mediace is saving money by denying claims. Most older folks will just pay the denied claims out of their pocket because they don't understand the benefits, are confused or don't have time to spend the day on the phone or are threatened with collections.

Do, I would say that sometimes the billers make mistakes and sometimes Medicare makes mistakes. You just have to be on the ball.

itsmagic · ‎08-08-2011

I’m over 65 and my doctor told me I could only get a pap covered by Medicare every other year. I don’t have any bad prior history so that was fine for me. I agree that maybe your last pap with your new doctor was billed wrong and they did not indicate you have a prior history.

granddi · ‎03-16-2010

@itsmagic wrote:
I’m over 65 and my doctor told me I could only get a pap covered by Medicare every other year. I don’t have any bad prior history so that was fine for me. I agree that maybe your last pap with your new doctor was billed wrong and they did not indicate you have a prior history.

I was just giving a personal story that showed that my claim was denied even though I know that if my claim had been filed accurately it would have been paid.

chrystaltree · ‎05-10-2010

Good grief, you seem to be sure of a lot things based on absolutely nothing. There's no way to answer your question because claims can deny for 100 different reasons. But I can say that "mistakes" by a doctor's or hospital's office are not the reason for most denials. I can also say that in this day of computer generated billing and computer generated denials, the vast majority of denials are correct. Most patients just don't to believe that. Timely filing denials almost never happen because that penalizes the doctor or the hospital. Why would a doctor or hospital file claims so late that the ensurer can't pay them? There is no appeal for that so it's throwing money away. Yes, sometimes there are diagnosis code errors and CPT code errors and HCPC code errors that cause a claim to deny and if you suspect that is the cause....after speaking with the insurance company.....you can ask the doctor's office or hospital if they will review the codes. That usually is not necessary because they want their money and they also received the denial notice, so of course they review the claim and correct any errors and rebill. They want their money. Generally when we get such a call our answer is "we corrected that claim and rebilled on 9/20". When something is denied, if you don't understand the denial, your first step should be to call your insurance company for an explanation. The c.s.rep will explain the reason for the denial to you and if necessary, you can call your doctor or the hospital but you know what to say to them. Your Pap issue is a benefit issue so you would ask your insurer about that first. Many insurers now only cover routine Paps every other year and the insurer defines what is routine. If the insurer says that a history of XYZ allows for more frequent Paps but your doctor did not list that as diagnosis. Then you would go back to the doctor's office and relay that information and ask them to update the diagnosis and refile the claim. Refiling is NOT a lot of trouble for any doctor or hospital, it's all done online now. You signed waiver which means that you are responsible for non covered services, copays, deductibles. A waiver does not mean that if they bill incorrectly, they can refuse to correct a claim and rebill. Always start with the insurer so you know what really happned and then go back to the doctor or hospital. And be calm and professional.

granddi · ‎03-16-2010

@Mz iMac wrote:
If you have a copy of your bill you can check the code & its meaning on a medical code website.

Also your Medicare EOB will give an explaination for the denial.

Fortunately I do know how to read and interpret an EOB. I was just curious what one of our experts here would say about the general topic of why claims are denied.

I believe many of the denials are caused by coding errors, clerical errors or other. Like our friend who shared story about the tetnus being denied.

I have direct knowledge that Texas Medicaid Clerks are bonused by the number of denials that they can find.