Using denial tracking to improve collections

April 10th, 2009 - Codapedia Editor
Categories:   Primary Care|Family Care   Billing   Collections   Denials & Denial Management  
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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


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