Top 5 Reasons for Claim Denials

Wouldn't it be great to have a Top 5 claim denial list? One Medicare payer is doing just that. Every month they release the top 5 claim denial reasons. After reviewing several months and several states, a pattern emerges. Knowledge is power so let's review Alabama's Medicare Part B top 5 claim denial reasons for February 2011.

1. NPI Missing for procedure code submitted. Services such as lab or x-ray require the NPI of the ordering provider. Consultations require the NPI of the referring physician.
2. Diagnosis code invalid for date of service. This is why it is so important to stay current on your code sets. The cost of staying current is less than the administrative costs of claim resubmission.
3. Paid amount greater than the allowed amount. “The claim was submitted as a Medicare Secondary Payer claim, and the primary paid amount for the line charge indicated was greater than the primary allowed amount”. Medicare Secondary Payer billing is also a top OIG Review item.
4. Invalid claim frequency. In this case, original claims were not marked as 1 for electronic claim submission. Other electronic claim submission issues relating to various “loops” were also reported. These issues usually need to be resolved with the software used to submit your electronic claims.
5. Paid and adjustment amounts do not equal claim charge on Medicare as secondary payer. Watch your fees and calculations.

These top 5 reasons seem to hold true for most states. Other states also had problems with:

• Using NPIs that don't exist,
• Using invalid Medicare ID numbers, and
• Line item charges of zero (only PQRI codes can have zero for the charge).

Interestingly, most of these problems are clerical issues. The benefit of using clearinghouses for your claims submission is that they can catch many of these types of issues BEFORE they are submitted to Medicare. If you do not use a clearinghouse, we strongly recommend that you create your own “audit sheet”. Make a list of these common errors and then make it your policy to review claims for these common errors BEFORE submitting them.

Another specific area to address is understanding how to correctly bill Medicare as a Secondary Payer (MSP). Two of the top 5 reasons are related to this subject. To help address this problem, special guidelines have been issued by CMS. CLICK HERE to download the Medicare Secondary Payer Fact Sheet.

Implement policies in your office today to reduce claim denials. It will increase your bottom line - and quite possibly your blood pressure.

Source: InstaCode Institute

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