It’s one of the unfortunate realities of being a medical biller or coder: sometimes there is an error and a claim will get denied. As if that weren’t bad enough, some claims can actually be denied on multiple accounts, meaning that additional problems must be rectified in order for the claim to go through. These multiple denials can be tricky, but a little extra work can help resolve them in the end.
In the first part of this series, we will look at what to do if a claim is denied multiple ways (for example, both insufficient medical necessity and a misused code) at the same time. If all the denials came together in the same letter, then you’re in luck. Since the multiple denials arrived at the same time, you can address them and send your appeals as part of a single letter as well. Many times, this will require coordination between billers, coders, and providers in order to determine the best way to fix the issues and support the codes properly.
From there, the best way to prepare for potential denials is to cover your bases from the beginning. For example, say that a patient was admitted for a procedure that was not part of the inpatient-only list. During the procedure, complications forced the hospital staff to admit the person as an impatient. Later, when reviewing the claim, the payer confirmed the medical necessity of the inpatient admission, even though that was not part of the precertified procedure. This case should be flagged, so that on the off chance that a similar scenario presents itself and results in multiple denials, this one can be used as an argument in the appeal. Be sure to save copies of all the original letters and documentation, as these will be invaluable pieces of evidence against the denials.