Identifying the reasons for delayed or denied reimbursements

Ear, Nose & Throat Journal, Dec, 2007 by Steven F. Isenberg

Figure. This hypothetical report shows representative examples of
reasons carriers might delay or deny payment.

Carrier      Reason for delayed or nonpayment

Aetna        Authorization is missing.
             Diagnosis code/CPT code is invalid.

Anthem       Patient cannot be identified as our insured.
             Payer deems payment denied for this many services on this
             date.

Cigna        Expense occurred after coverage was terminated.
             Payment was adjusted because of coordination of benefits.

Humana       Charges are not covered.
             Payment is included in the allowance for another service.

Medicare     This procedure is not reimbursed separately.
             Patient is covered by a managed care plan.

Sagamore     Patient's identification number is missing or invalid.
             Procedure code is inconsistent with the modifier.

If you are not being paid when you should be on a regular basis, it is imperative that you find out why. A good first step in accomplishing this is to compile a report that specifies all the reasons given by insurers for late, incorrect, or denied payments (figure). For example, some payments may be delayed or denied because of coding errors. In other cases, missing information is to blame. Finally, some reasons are not even legitimate.

Once the reasons for delayed or denied reimbursements are crystallized in an organized and compact format, identifying and solving recurrent problems should become easier. These reports should be reviewed monthly so that you can appeal quickly. Often, a phone call is all it takes to rectify an inappropriate denial. For example, a carrier's representative may simply explain that his particular company has special coding rules--rules that you were not aware of.

Billing is a team effort, and you, as leader of the team and the primary coder, should continually hone your skills. So be an active participant in the team-billing concept. It's your business, and correct billing is ultimately your responsibility.

Steven F. Isenberg, MD

Dr. Isenberg is an otolaryngologist in private practice in Indianapolis; sisenberg@good4docs.com