Author Topic: Denials  (Read 1423 times)


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« on: December 20, 2014, 10:52:12 AM »
I just started working at a billing company, and had a few questions on denials:

1st question:  When you get a denial for no referral or authorization?  I always thought you had to notify the client to have them double check to make sure it was done.  I was told you put it to patient responsibility, but I don't think this is right. I always thought it was the staff's responsibility to run eligibility,and get auth's and referrals before the visit, and if they didn't do that, then it had to be adjusted off?

2nd question: When the claim is denied because the diagnosis wasn't deemed medically necessary according to the LCD. Wouldn't you let the client know and refer them to the LCD or would you just check the patient's notes, to see if there is another diagnosis in the note that supports the procedure, and if so just do a corrected claim?
Any suggestions would be greatly appreciated!  :)


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Re: Denials
« Reply #1 on: December 20, 2014, 04:47:03 PM »
The billing companies I work for handle things as follows:

1. The staff/doctor is notified there is a denial for no auth/referral, and if they did get it, but didn't let us know, we submit a corrected claim with it. If they didn't get it, we go by what the EOB says...which is normally a write-off, and NOT patient responsibility. And we educate the staff on the importance of obtaining all necessary referrals/auths. We also try to have the staff get the auth/referral retroactively, but that is not always possible.

2. I let the client know about the denial, and refer them to the LCD for covered dx's. They then tell me what I can change the dx to, if in fact that patient has that dx. If not, whether we write the charge off or bill the patient depends on what the EOB says, and what insurance the patient has...meaning if it is Medicare and there should have been an ABN, but the provider didn't get one, it is a write off. While I have access to all patient notes, I cannot as a biller autonomously change a dx without talking to the doctor.

Obviously, in a perfect world, things like this would not happen, but they do, and sometimes a lot, depending on how educated staff/doctor are about this kind of stuff. In some cases, it IS the billing companies responsibility to run eligibility, etc, and tell the staff what auths/referrals are needed, before the patient is seen. It just depends on what services the billing company is contracted for with the client.