As the Wimbledon competition comes close to its end this Sunday, July 6, I am publishing the last of my three part series comparing medical billing complexities to those of tennis scoring.  

In Part 1, the referral/authorization requirements of managed care plans was discussed. 

For Part 2, the topic was claims denials based mainly on CCI edits or duplicate entry errors. Unfortunately, billers encounter many other claim denial reasons. 

 

Point Three (or Forty in Tennis)

Non-covered Services

 

From many years of working in radiation oncology, I became all too familiar with the

“non-covered service” or lack of medical necessity type of denials. 

Procedures that are performed but do not fall within the scope of the commercial payer’s medical policies or in the case of Medicare the National Coverage Determinations (NCDs) orLocal Coverage Determinations (LCDs).

 

Medical billers must have an intricate knowledge of the procedures performed in their office and the coverage exceptions for each of their payers.  This often entails numerous hours of research on commercial payer websites locating and reviewing the Medical Payment Policies or Coverage Guidelines. 

Thankfully, CMS has a well-organized search tool in the Medicare Coverage Database that greatly facilitates finding this information for Medicare beneficiaries.

 

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Once the research is complete, it is important to share this information with other office staff, especially those that schedule procedures.  Initiate an office procedure to alert the appropriate staff when these services are planned for a patient.  It is much easier to work with the situation prior to the service being rendered.

On more than one occasion, I had this conversation with the Radiation Oncologist:

Me:  Sally the schedule coordinator told me you were ordering IMRT for Mr. Jones.  I checked the coverage for the IMRT procedure for Mr. Jones and Medicare will not cover it for that diagnosis.

Dr.: Well, IMRT is necessary for this patient.  It is the appropriate and safest treatment for his condition.

Me:  If we perform this procedure, it will be denied.

Dr.:  I am going to provide the best care for the patient, can we appeal it?

Me:  Yes, we can appeal it, but it may still not be covered.

Dr.:  I don’t care.  It’s my job to help the patient and this is what he needs.  If we don’t get paid, that’s fine.

Me:  Okay, then I will need you to be very specific in your documentation that I can use for the appeal.  The more details you include that justify your treatment choice will help our case.

  Dr.:  I will take care of the documentation.

 

As I predicted, the claims were denied, but because I had discussed this beforehand with my physician, the documentation was impeccable.  Most of the time, the denials were overturned via the appeal process. 

Commerical payers will often times allow for a pre-determination review for procedures that may fall out of the scope of the coverage guidelines.  I have seen these reviews take up to 30 days, so getting it started as soon as possible is crucial and can be facilitated by that notification process mentioned earlier.

 

Encouraging thorough communication throughout the medical practice should be a top priority. 

This aids the medical billing staff in facilitating the optimum claims reimbursement for the practice.