Let's focus now on how to reduce denials by insurance carriers for your chiropractic claims.
In case you didn't know, I had the distinct privilege of working as an Insurance Claims Analyst before and during chiropractic college. (Go ahead and throw darts, but this experience of mine is going to help you out in a few short minutes, so hold on to your sharp objects!)
Although I worked for the insurance company (largest health insurer in the state of California at the time) over a decade ago, much of what we see going on today is the same as then -- it's just become worse!
So here are a few tidbits that I learned from my Claims Analyst work, along with a few more I've gained more recently on the way through my professional coders association and my role as a consultant to chiropractors throughout the country.
Use Appeals to Your Advantage
The first thing you need to realize is this, the more you appeal your denied claims the less likely they are to deny them in the future for bogus reasons. Most practices think they made the mistake when they get a denial from a carrier and so they don't appeal because they believe they will get more denials. That is just not the case.Yes, I said that correctly. Here's why.
Approximately 30% of all claims submitted to an insurance carrier on the initial submission are denied whether they are correct or not.
They do this because less than 25% of all medical practices in the U.S. appeal their claims. That figure just blows my mind. In fact, that was the case when I was working in insurance, the numbers may be a lot worse now.
Steps to Reduce Denials
If third-party payers are going to randomly deny bills just for fun and because they know you won't fight back, what CAN you do to reduce denials when billing to insurance carriers?
1. Make sure you are using the most current versions of the CPT, ICD-9 and HCPCS. It bugs me to no end to consult with clients who tell me they are "reasonably confident" in their billing practices and when I look over their fee schedules, I find codes that haven't been in use for years. This is easily remedied: get the updated code books and use them!
2. Ensure the proper usage of modifiers on your claims where appropriate. Just recently, I consulted with a doc who didn't understand why all of his exams were being denied when he billed for them along with an adjustment. "The correct answer, Alex, is 'What is a modifier?"
3. Utilize the Correct Coding Initiative (CCI) in your defense. If you are up to standard as far as the CCI goes, use it when appealing denials and defending your billing. If you think that CCI is a popular crime-fighting drama on TV AND you select your own CPT/Billing codes, you may be in deep trouble. Even though I don't own a TV, I am aware of the CSI show. You, on the other hand, know just enough coding to be dangerous.
4. Use the Internet to search for policies from the various carriers Many carriers post policies online, which most chiropractors seem to be unaware of the fact that. I typically have to give one bit of bad news per month to a DC who is upset on how his carrier is paying or not paying for a particular service. Unfortunately, when I look up the carrier policy, they are complying with their own rules. Sorry, Charlie, you signed the agreement to be a provider and this is how they say they will pay. No appeal necessary. You lose.
5. For those payers with a formal appeals process such as the Federal and State programs, know your appeal rights and the various steps involved with the process. Kind of like calling the wrong number and wondering why the person for whom you left a message never got it. If you appeal to the wrong entity, don't expect success. Do your homework.
There are, of course, several more steps you can take to reduce denials but these are the basics you need to be aware of because they are the ones that I routinely see doctors making mistakes.
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