Practice Management Alert

All explanations of benefits (EOBs) for denials are not alike, and if you can't distinguish between them, your appeals could be worthless. Review these common EOB denials and respond with adequate specification. Details come from Thomas Kent, CPC, CMM, president of Kent Medical Management in Dunkirk, Md.

You don't have to worry about appealing denials with this "noncovered" denial. It means the contract between the subscriber (that is, the patient) and insurer says that the insurance won't cover the patient's cost for this service, Kent says. Your insurer hasn't short-changed you or violated your contract. If you see this EOB, bill the patient, sending him or her a support letter explaining the situation, and have the telephone numbers of insurance representatives available in case the patient questions the payment and the insurer's denial, Kent says.

Pay attention to this EOB. The denial code indicates that your provider's contract with the insurance company supports the insurer's denial for this service payment, Kent states. If you see this EOB, check to make sure the contract explicitly mentions denying the service. If it's denied in the contract, you must accept the insurer's denial. Inform your providers about the denial, for future services, and address the issues during contract renegotiations.

If the contract does not deny the service, then you should appeal "vigorously," Kent says. Send a letter to the insurer, explaining that you don't see the denial in the contract, and request a copy of the notice that makes the denial part of it, he states

This denial code tells you that the diagnosis code on the claim doesn't support the service. Medicare has been using this denial for a while, but other insurers are now applying it, Kent warns. An example of improperly diagnosed claims would be an encounter form listing a sprained ankle diagnosis first, and fever second, to justify a urinalysis. The fever needs to occupy the primary diagnosis spot, he says, to support medical necessity for the urinalysis.

Appeal "not medically necessary" denials on downcoded claims. Insurance companies may say a diagnosis doesn't support a particular level of service, but they can't determine a level of service based on a diagnosis code without looking at documentation, he says. The insurer is pushing what Kent calls a "trial balloon" to see if you'll notice the money you're losing. Appeal these claims, but check to see that you're using the most specific diagnoses codes for all documentation, and avoid unspecified diagnosis codes, he adds.

Make sure insurers are following CPT and the NCCI edits on these claims, Kent says. Insurance companies shouldn't make up their own bundles, he says, unless, of course, they explicitly add them to a contract you approve.

Look out for denials for bundled services that the most recent quarter of NCCI edits rescinded, says Jason R. Levine, JD, a consultant and senior editor for Murer Publications at Murer Consultants Inc., a legal-based healthcare management consulting firm in Joliet, Ill. Check to see if your payers are up-to-date on what the NCCI edits have withdrawn as well as bundled, he says.