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Claim denials are one the most significant challenges faced by healthcare providers, including chiropractors. According to a July 2022 Kaiser Family Foundation report on CMS data about claims denials and appeals by health plans on the federal health insurance marketplace varied among payers, and was as high as 80% for some plans. Working with a chiropractic billing company is a practical option for practices facing an increasing number of claim denials. Denial management experts will analyze the reasons for claim denial and take proactive steps to appeal denials and implement proper claim submission processes to prevent further issues. This will boost cash flow, reduce costs, and enhance practice efficiency. A Chiropractic Economics report notes that more than 60% of all claims denied on first adjudication, are eventually paid on appeal.

Reasons for Claim Denials

While taking time to appeal chiropractic claim denials, it’s important to know the reasons why. An American Chiropractic Association article categorizes denials into two types — administrative and clinical.

Mistakes in paperwork cause administrative denials. Reasons include:

  • Lack of prior authorization – not obtaining prior authorization before the service is provided can lead to claim denial.
  • Missing ∕ incorrect information – This can include a missing Social Security number or demographic information, wrong plan code, or a missing modifier.
  • Noncovered or excluded services – This error occurs when the patient’s plan is not reviewed before submitting the claim.
  • Out-of-network provider – if the services are performed by a provider that is not contracted with the insurance company, all or part of the claim may be denied.
  • Duplicate claims – Duplicate service denial occurs when the same service was performed on the same patient on the same date and by the same provider.
  • Bundled claims – Instead of paying fees for two separate services, the payer groups or bundles two charges and pays only one, smaller fee.
  • Service denied because payment already made for same/similar service(s): This type of denial occurs when the benefit for the service or procedure is included in the allowance or payment made for nother procedure.
  • Coordination of benefits – Claims for patients covered by more than one health plan can result in delays and even denials if the patient’s coordination of benefits is not up-to-date.
  • Exceeded timely filing limit – This happens when a claim is filed after a payer-determined time limit. As this time frame can vary among payers, knowing what that time frame is for each payer is critical.

Reason for Clinical Denials

  • Medical necessity requirements not met – Reasons that prompt such denials include: inpatient criteria not being met, inappropriate use of the emergency room, length of stay, or inappropriate level of care. Payers require clinical documentation that supports billing of the length of stay, service provided, level of care, and reason for admission. The physician’s admission order should clearly identify the level of care.

Submitting Appeals for Chiropractic Claim Denials

When submitting an appeal, make sure you understand the payer’s policies and appeals process. This will help you respond properly to the carrier’s actions. On its website, the ACA provides six steps to appeal denials. Expanding on these steps:

  1. Read the ACA’s coding clarifications to ensure you are coding correctly: Improper coding leads to costly resubmissions and time for appeals. Make sure the CPT codes accurately represent the services or treatment provided. Ensure that the Explanation of Benefits (EOB) is accurate and matches diagnoses, CPT, etc. Double check all modifiers for accuracy.
  2. Review your documentation to ensure the procedures billed are supported in the patient health record and compare your documents to the ACA documentation guidelines. Ensure that medical documentation is accurate and appropriate. The diagnoses must be accurate and fully support the medical documentation.
  3. After ensuring that coding and documentation are in accordance with the ACA and CPT guidelines, use ACA’s template appeal letter for your specific situation.
  4. Go to the state insurance regulations page and check if any of the information from your state insurance regulations supports your appeal.
  5. If you receive no response for the first appeal, follow the insurer’s instructions to make a second-level appeal.
  6. If you don’t receive a response to your second appeal, notify your Department of Insurance and include all correspondence from the insurer.

Make sure your office keeps records of communication with payers: method of contact used (phone, email, in-person conversation, letter, etc.); date on which you contacted the company; name of the person you talked to, and what was said. Keeping detailed records is important as insurance companies usually admit to and honor any mistakes they make. Prior authorization appeals must be submitted within 90 days of the date of the authorization denial. Your staff must also be familiar with the additional requirements for expedited and urgent expedited appeals as well as the levels of appeals for Medicare denials.

With proper appeals and denial management processes in place, chiropractic practices can protect their revenue and increase cash flow. Medical billing companies that provide chiropractic billing services can ensure proper revenue cycle management to prevent denials. If your office is struggling with denials, they will help you submit appeals to recover otherwise lost revenue.

OSI’s professional team stays up to date with the latest codes and is knowledgeable about the claim submission requirements of leading insurance companies. Send out clean claims and optimize revenue cycle management – call (800) 670-2809 today!

Loralee Kapp

Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI.

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