Administrative Vs Clinical Denials
Administrative and clinical denials are the two major types of denial claims. Both of them appear in different ways.
Administrative Denial: These are the results of errors on the claim, such as an incorrect ID number, a misspelled name, or an incorrect date of birth of the patient. Resolution for administrative denials involves correcting the error(s) and then again refining the claim with the payer.
Clinical Denial: This denial occurs when a payor questions the medical necessity of a procedure or treatment or labels it as an investigational or an experimental. An absence of pre-authorization is another reason for clinical denial. If you have already sent it in with a claim, you can’t just go back and submit the pre-authorization to affect the fact. When appealing the clinical denials, will be require by the chiropractors to fill out a lot of paperwork within 30, 60, or 90 days.
All of the chiropractors who know how to properly combat the insurance denials will fare better than their peers and remain financially solvent. Your chiropractic billing services staff needs to make some efforts to avoid such common mistakes and follow up on all denials and rejections.
Below are The Few Reasons
Missing Claim Information
Any missing information from the HCFA 1500 form can cause denial claims. The most important missing element is the date of onset. Make sure to scrutinize all claims for missed fields and require supporting documentation.
Claims Contain Incorrect Patient Identifier Information
To avoid these errors, make sure that there are no spelling mistakes in the name, date of birth, and sex of the patient. They all must be accurate. The correct payer enters the policy number should be valid. It’s a good idea to check whether or not the claim requires a good number, the patient’s relationship to the insured is correct and the diagnosis code matches the performed procedure. In the end, make sure the primary insurance is listed as such in the case of multiple insurances.
Avoid Documentation Issues
The golden rule of chiropractic billing services is “documentation drives billing”. Now, the question is, “What is the meaning of this rule?”. Accurate and compliant documentation will lead the way toward the correct assignment of codes. In turn, this can help provide the provider with maximum reimbursement, fewer denial rates, compliance, and peace of mind.
Requires Pre-Authorization and Pre-Certification
For plans with pre-authorization procedures in place, the working principle is straightforward. Your claim for those services will be rejected if you don’t get the necessary pre-authorization. This is the most basic method by which plans might appear to offer patients a lot of visits while allowing them to pay for significantly fewer. For example, a plan can specify that a patient gets 24 chiropractic visits annually (subject to pre-authorization). But, if the insurance only covers 10 visits, the patient will forego the remaining 14 appointments (and will not be reimbursed by the payer).
You cannot bill the patient for any services that are not paid for if you are a contractual provider and fail to get pre-authorization. Your claims will also be rejected if, on the other side, you are NOT a contracted provider (for example, if you are out of network) and you do not adhere to the pre-auth process. Yet, you can charge your patient for the services that were refused.
You MUST have a successful and efficient plan in place if ANY insurance plans in your area need pre-authorization; otherwise, you risk losing patients, time, and money by not taking proactive measures.
Lack of Coverage in Patient’s Insurance Plan
There could also be some problems with the patient insurance plan. This may show up in several different ways. For instance, even if your patient believes they have current insurance coverage, they may not. They might be mistaken about the number of visits or the kinds of visits that are covered by their plan, or their plan might not cover chiropractic care.
Before delivering care, you should confirm your patient’s insurance to help reduce this issue. When accepting a new patient, you should have all insurance concerns resolved. You should also frequently review an existing patient’s eligibility. Once a year, it’s a good habit to check for changes in patient insurance coverage.
Common Reasons for Medicare Chiropractic Billing Services Denials
Very limited coverage offers by Medicare for chiropractic billing services. Below are a few common reasons for denying claims.
- The date of the start of treatment is not provided or is incorrect.
- There is no subluxation diagnosis code in the claim.
- A chiropractor is the service provider, and the reported procedure code is not 98940, 98941, or 98942.
- The AT modifier is absent from the CPT codes for chiropractic
- The LCD does not indicate the diagnosis code
How Can You Avoid Chiropractic Billing Services Denials and Delays?
Instead of possibly wasting an hour or more trying to resolve a refused claim, it is a good habit to periodically spend a minute or two reviewing each claim before sending it for approval. Search for patterns in the delays and denials, and act rapidly to correct any errors in subsequent claims. Last but not least, make sure you give claim denials some thought. By choosing not to challenge denials, you’re indicating to insurance companies that you concur with their judgment and raising the possibility that other claims will get reject or delayed in the future.
Best Ways to Manage Chiropractic Billing Services Denials
Managing denials manually takes a lot of time. You should concentrate on denials that will result in the greatest return upon appeal to ensure that the time you invest is beneficial.
- Fastest Payment
- Highest Value Denial
- Highest Probability of Payment
Outsourcing your Chiropractic Billing Service to An Expert Team
Chiropractic billing services require more explicit accounting practice other than traditional medical billing claims and mistakes can lead to a headache when having to deal with insurance companies that are hesitant to cover services.
Alliance PMB is a full Healthcare Medical Billing in the USA. It handles the whole procedure of revenue cycle management.
