Here are some examples of denials that a practice should track to be sure that they are paid correctly by the insurance company.  Set up a denial type for each of these. 

Fee Schedule Issues:

• Wrong amount paid per the contracted fee schedule. May be too high or too low
• Modifier 80 paid incorrectly. If paid at less than 20% or 25% of commercial fee schedule amount, or 16% of Medicare fee schedule amount, may be paid at wrong level
• Payments for other modifiers (50, 51, 59)—were they paid correctly
• Evaluation and management services on the same date as procedures, -25 and –57 modifiers
• Network problems with TPA’s and networks—being asked to take a reduction if you are not part of the network

Incorrect processing:

• Multiple procedures, modifiers (does the staff really know how to use the NCCI edits, and to appeal claims that are incorrectly denied?)
• Modifiers have a lot in common with monopoly
• Unit issues. We bill for 5 units and are paid for 1 unit
• Codes that the insurance company says are “one” and CPT® and we say are “each”
• Variation in processing from claim to claim
• Specific billing for their processing
• Anesthesia quirky requirements
• Lines with $0 payments