An excellent question which is usually met with a variety of answers. Detailed below are some of the more common reasons a claim is not being paid and steps to correct (or avoid) them in the future.
No Referral: For some time, the medical home model had started to disappear. Patients were allowed to self-refer to a specialist without first seeing their Primary Care Physician (PCP). Unfortunately, the medical home model for some HMO plans is starting to see a resurgence. For some plans, you will now be required to obtain a referral from the PCP before rendering any care or services. This includes a new patient examination and a diagnostic ultrasound. Be sure to ask for ALL possible codes when you begin treatment including ultrasounds, needle guidance, follow up office visits as well as the proposed procedures. The only ‘good’ news is that the PCP is usually willing to backdate a referral.
No Authorization: Many commercial plans require a prior-authorization prior to treatment. Unlike the referral, most authorizations are only required for procedures. Be sure to review the ‘window’ of time you have for the authorization. We frequently see denials for no authorization because the date of service was after the authorization’s end date.
Another reason for a No Auth denial is due to a ‘game day’ decision. For example, you had intended to do some sclerotherapy but, after further review that day, you decide to perform a phlebectomy. Have your staff immediately call either before or just after the procedure to modify/add the phlebectomy code to the authorization in place.
Non-Participating: With the increase in various plan types being offered by the several payers, this type of denial is on the increase. You may be contracted for BigGulp PPO, HMO and Medicare Advantage but suddenly find out (after the fact) that you were not added to the BigGulp EPO plan which has no out-of-network benefits. When calling for benefits on a patient, and it is a sub-plan you have not really seen before, be sure to double-check whether or not you are in network for that sub-plan.
Patient is in an Independent Practice Association (IPA): These are very common in California with a few migrating out to other areas. One must be careful in reviewing the patient’s card. It may say United but elsewhere on the card it will note that the patient is covered under an IPA administered plan. The IPA will typically never allow the patient out of their financial control. Gaining a contract with the IPA to see their captured lives is also extremely difficult.
Not a Covered Benefit: We are seeing this type of denial for some of the newer technologies. Be sure to review the payer’s policies before providing care using one of these technologies. While a laser or RF ablation may be covered, it may not be allowed using some other methodology. As always, be sure to review exclusions to the treatment of varicose veins. CIGNA’s self-funded plans seem to have this ‘rider’ on the policies sold. Be wary of patients on a COBRA plan as well. We have seen some COBRA plans with a more limited benefit set than what the patient enjoyed while fully employed. We recommend double-checking with the plan to ensure varicose vein treatment is still covered.
Not Medically Necessary: We have covered this in other articles. In brief, be sure your H and P and diagnostic US clearly reflect the need for care, that they match or exceed the plan’s requirements, and that any conservative therapy is completed as required.
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