Working Common Denials (part 2)

Donna White

Donna White

By Donna White, Principal Consultant and Owner of Legacy Consulting Services and Legacy Billing Solutions in Montgomery, Alabama.

In today’s article, we are going to continue to review best practices for follow up on some of the most common denials, regardless of specialty.

Missing Information
There are several types of common Missing Information denials. First you may be missing Medical Records. In this case, the payor needs the chart or progress note to process the claim. Call the payor and see if the records can be faxed. Be sure to ask what additional information is needed so there are less chances of a future denial. If the records have to be mailed, get the correct mailing address as it may not be the same as the claims mailing address.

Another common Missing Information denials are tied to Worker’s Comp accounts – Missing date of accident/onset date, Accident type, or State where accident occurred. This should be in the system. Check appropriate claim area to make sure the information was entered correctly and transmitted on the claim. Make sure that information made it correctly to the clearing house. If the claim is correct and accepted at the payor level (which it should be if you have a denial), call the insurance company and speak with a representative to have the claim reprocessed. If it has not been entered in the appropriate area, check the initial evaluation for accident or onset date.

One more common Missing Information denials is Missing Modifier or Missing Appropriate Modifier. You must be sure you are following correct coding procedures before you add a modifier. Make sure you understand what the modifier means and review the medical record for that date of service to ensure that modifier is appropriate. If you have a coding department, it may be best to send back to them for review to update the claim with the correct modifier.

Coordination of Benefits
Per the EOB, the patient’s service denied for Coordination of Benefits or COB. This typically means that the insurance that was billed was not billed in the proper order. Perhaps when the patient gave their insurance information, they gave it in an incorrect order.

Check the insurance listed as secondary and do either online or over the phone eligibility. Speak to a representative if possible to confirm if that payor is indeed the primary insurance. Also, if the patient had Medicare listed as secondary, check eligibility on the Medicare website – it will tell you the effective date and whether the insurance has a secondary or a Medicare replacement plan (MSP – Medicare secondary payor).

Use the payor website or call to re-check eligibility for the payor that denied. Find out if their records show themselves listed as primary or secondary (or tertiary if applicable). If you are able to confirm that the secondary payor listed in the Insurance screen is indeed the primary and the current listed primary should be the secondary, follow the procedures for updating insurance plans in your Practice Management system.

If you are unable to determine which payor should be listed as primary and which secondary, call the patient to see if they know. Likewise, if both insurance companies claim to be primary, call the patient and let them know that they will have to call both insurance companies to correct which is primary and which is secondary.

Today we have reviewed some of the more common denials across specialties. Keep an eye out for future articles regarding working more popular denial types.

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