Top Claim Error Revealed
- By Renee Dustman
- In Audit
- July 12, 2019
- 4 Comments
The No. 1 claim error for June in 11 states plus the District of Columbia was for non-covered charges, according to Novitas Solutions, Medicare Administrative Contractor for Jurisdictions H (Arizona, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas) and L (Washington DC, Delaware, Maryland, New Jersey, and Pennsylvania).
This error is identified by Explanation of Benefits (EOB) message 96. Noncoverage has been the No. 1 claim error for some time in these states, which is hard to believe because there’s a known cause and cure.
Preventing EOB 96
Prior to performing or billing a service, ensure that it is covered under Medicare. Granted, this is sometimes easier said than done. The requirement for prior authorizations, for example, can lead to delays in needed healthcare, affecting both patient outcomes and patient satisfaction, sympathizes John Verhovshek, MA, CPC.
And it can be confusing because not everything requires preauthorization. The Centers for Medicare & Medicaid Services (CMS) keeps a master list of items frequently subject to unnecessary utilization, which is used to identify durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) subject to prior authorization as a condition of payment.
Being able to tell a patient whether their insurance covers a health service is an important part of the patient experience, however. The patient experience encompasses the entire range of interactions that patients have with a healthcare system, explains MariaRita Genovese, CPC.
Remedying EOB 96
When a claim is denied for non-coverage, review the medical documentation to determine whether the appropriate procedure code was submitted. Also view the national and local coverage determinations to verify whether the applicable diagnosis codes support medical necessity for the procedure. If everything looks right, and you have evidence to support the claim documented in the patient’s chart, the next course of action is to submit an appeal request.
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Thank you for the valuable information 🙂
Will you make recommendations on GZ & GY modifiers to ensure the EOB comes back stating PR for patient responsibility to allow billing to patient or other supplemental carriers?
GY and GP modifiers on known excluded services allow for the PR on the EOB. It is because there may be coverage from a secondary insurance that we have to be able to submit some of these. These modifiers work perfectly when used correctly.
I think that is unfair that we have this held against us if the supplemental plan will cover the charges. We have to get the denial in order to get paid from them.