Dealing with Denials

In the ideal world, all claims for medical services would be paid without question. But we work in a less than ideal world, and claim denials are a part of our daily work. Handling those denials effectively is our highest priority. Success with those denials is contingent on the situation and the quality of the documentation that supports the service.

What sort of denials do we see on a daily basis?

We may have a denial for a patient who has used all of their benefits for a year, or has a large deductible. Those denials are out of our hands, and billing the patient is the only resolution.  We may have a denial for missing authorization, and a quick explanation of the ‘blind provider’ scenario will generally get those cases paid.  A greater challenge comes from denials that are created from the broad range of ‘not medically necessary’ issues.  With these cases, we have an opportunity to obtain payment, but only after submitting medical records and a supporting letter that demonstrates the validity (medical necessity) of the service. 

‘Not medically necessary’ denials generate from many policies and vary from carrier to carrier. There are those policies that are fairly consistent with all carriers, as we are seeing with what used is commonly known as a ‘MAC denial.’ Others are specific to a certain carrier, such as the denial from UHC for treatment of occipital headaches by a chronic pain provider.  Lack of a specific diagnosis can create a denial: if the diagnosis on the claim does not clearly support the service, the claim will deny.  Carrier policies will delineate the diagnosis codes that are valid and use of any other code will create the denial. Frequency of services can also cause a denial. With anesthesia, two cases on the same day will require an appeal, while chronic pain providers have limits to the number of times a certain injection can be performed in a given time frame.

What are the most frequent denials for anesthesia providers?

The two most frequent denials for anesthesia providers are cases that fall under the ‘MAC policy,’ and postoperative pain blocks. ‘MAC denials’ are driven by the assumption that the surgical procedure did not require the higher level of anesthesia and could have been performed under moderate sedation. ‘MAC denials’ can be a misnomer as the denials are not limited to MAC cases; general anesthesia cases fall under the same criteria for payment. Postoperative pain blocks are denied as bundled to the surgery, and/or were not requested by the surgeon. For chronic pain providers, repeat treatments over a period of time, or escalating treatment without attempting conservative therapies are the most frequent denials and will require review of documentation over a period of several months to demonstrate the validity of the treatment plan.

Every denial must be reviewed and an appeal prepared.

Provider documentation is crucial to the success of appeals. For anesthesia service denials, we must provide the anesthesia record, with preoperative and postoperative assessment, and sometimes the surgeon’s operative report. For chronic pain cases, we often must provide documentation of a chain of events over a six month period.

How can providers help improve our success with appeals?

Create the best documentation possible!  Write legibly, and provide complete diagnoses for all procedures and complete documentation of all variables of the case. With electronic medical records, we are seeing providers relying on entries by nurses to list the procedure being performed and the diagnosis, which is often entered prior to the surgery, and is not an accurate reflection of what actually transpired in the operating room. To avoid this inaccurate representation of your service, always update EHR information if the situation changes from what was originally entered.

Clearly explain extenuating circumstances: is there something particular about this case or patient that warrants special treatment? Anything that is unusual, causing a concern for increased risk, complexity or time should be documented. 

Appeals for MAC denials

MAC denial appeals would benefit from documentation of such things as weight and height of an obese patient to validate BMI, history of problems with previous anesthesia or failed sedation, anxiety at the time of the service, Mallampati score or STOP BANG score. Postoperative pain blocks require documentation of request by the surgeon as well as clear documentation of the nerves being blocked.  Chronic pain providers should document changes in condition and previous treatments with outcomes, as well as a percentage of improvement statement after each procedure.

From Complex Claims, To Codes

Claims to insurance companies are translated from extensive medical records to a few simple codes.  Unfortunately, this process of coding does not cover all the variables encountered with every patient. Appeals will always be necessary as denials will always occur. We are most successful with appeals when we have excellent documentation from our providers that helps to explain those variables that do not translate through the coding mechanism.  Extra attention to details on unusual cases will go far in creating a successful appeal that results in payment of the claim.

Article Contributed By: Melanie Lafferty from Medac

Melanie Lafferty joined Medac, an anesthesia billing and practice management company, as Vice President of Practice Management in October 2013.  Prior to that, Ms. Lafferty worked for over 20 years in the areas of anesthesia and pain management billing, practice management, coding and compliance. Her experience includes practice management services for a wide variety of anesthesia provider organizations located across the country, the management of client teams that provide revenue cycle management, and lead roles in managing new client implementation processes.  She has also provided guidance with group formation, hospital relations, and payer negotiations.  Ms. Lafferty has been a presenter at many Billing, Coding, and Compliance seminars across the country over the last few years and continues to be a resource for many Anesthesia Associations for help in these areas.