Denied or delayed chiropractic claims can adversely affect the financial health of your practice by reducing cash flow. Studies have revealed that year on year; chiropractors lose as much as 30% of their potential and earned revenue due to claim denials and reimbursement delays. As a chiropractor, it’s important to understand why your claims are being denied and take the time to appeal these denials.
Administrative vs Clinical Denials
The two main types of insurance denials are administrative and clinical. These are appealed in different ways. Administrative denials are the result of errors on the claim form such as an incorrect ID number, misspelled name or an incorrect date of birth. Resolution for administrative denials typically involves correcting the error(s) and refiling the claim again with the Payer.
Clinical denials occur when a Payer questions the medical necessity of a procedure or treatment, or labels the procedure as investigational or experimental. Another major reason for a clinical denial is the absence of a pre-authorization. If you’ve already sent in a claim, you can’t go back and submit a pre-authorization after the fact. When appealing clinical denials, chiropractors are required to fill out a lot of paperwork within a 30, 60 or 90 days time frame.
Chiropractors who understand how to properly combat insurance denials will fair better than their peers and remain financially solvent. Your billing staff should make every effort to avoid these common mistakes and follow-up on all denials and rejections.
1. Claim is missing information
Any missing information from the HCFA 1500 form can cause a claim to be denied. The most common missing item is the date of onset. Be sure to scrutinize all claims for missed fields and required supporting documentation.
2. Claim contains incorrect patient identifier information
To avoid this error, make sure the patient’s name is spelled correctly, the date of birth and sex are accurate, the correct Payer is entered and the policy number is valid. It’s also a good idea to check whether or not the claim requires a group number, the patient’s relationship to the insured is accurate, and the diagnosis code matches the procedure performed. Finally, make sure the primary insurance is listed as such in the case of multiple insurances.
3. Documentation issues
The golden rule of medical billing is “documentation drives billing.” Now what does this rule mean? Simply put, if it is not documented, it was not done. Accurate and compliant documentation will lead the way to correct assignment of codes. In turn, this can help provide the Provider with maximum reimbursement, lower denial rates, compliance and peace of mind.
4. Requires prior authorization or pre-certification
If you are a contracted provider and don’t obtain pre-authorizations, your payment is denied and you cannot charge the patient for any denied services that you rendered. On the other hand, if you are NOT a contracted provider (ex: out of network) and you fail to follow the pre-auth process, your claims will also be denied. However, you can pass the cost of those denied services on to your patient.
If you have ANY insurance plans in your area that require pre-authorization, it’s imperative that you have an effective and efficient strategy in place otherwise you will potentially lose time, money and patients by not taking proactive steps.
5. Lack of coverage in patient's insurance plan
Certainly, there could also be problems with a patient’s insurance plan, too. This can manifest itself in a variety of different ways. For instance, your patient may not actually have current insurance coverage even if they think they do. Their plan may not cover chiropractic care, or they may be wrong about how many visits or the types of visits that are actually covered.
Verifying your patient’s insurance before providing care can help minimize this problem. You should have all insurance issues sorted out before taking on a new patient and regularly check eligibility for existing patients. It is a good habit to check patient insurance coverage for changes once a year.
Common reasons for Medicare chiropractic claim denials
Medicare offers very limited coverage for chiropractic services. These are some common reasons for Medicare denials.
- The initial treatment date is not reported, or not a valid date.
- The claim does not include a subluxation diagnosis code.
- Provider is a chiropractor and procedure code reported is not 98940, 98941 or 98942.
- Chiropractic CPT codes are missing the AT modifier.
- Diagnosis code reported on claim is not listed as a covered diagnosis per the LCD.
How to reduce chiropractic denials and delays
It is a good practice to regularly spend a minute or two on each claim before sending it for approval, rather than potentially wasting an hour or more resolving a denied claim. Look for commonalities among the rejections and delays, and work to quickly fix any mistakes in future claims. Finally, be sure to take the time to appeal claim denials. By not appealing denials, you’re telling insurance companies that you agree with their decision and increasing the likelihood that future claims will also be denied or delayed.
The best way to manage denials
A manual denials management process is time intensive. To make sure the time you invest is worthwhile, you should focus on denials that will yield the highest return when appealed.
- Fastest Payment Opportunity. Review your historical claims and remit data to track when you received denials and when you received the correct payment back from the payer. By measuring this, you can determine what types of denial reason codes have the shortest appeal resolution time to help you get money in the door faster.
- Highest value denial. When you receive denials, look at your historical data to determine and track how much you typically get paid for the type of services provided on the claim. Focus on appealing claims that bring in the highest amount of revenue.
- Highest probability of getting paid. Focus on denials that you can most easily fix, such as denials where information was missing from a field or where coding or data was incorrect due to human error. You can easily fix this information and resubmit the claim.
Outsourcing your chiropractic billing to an experienced team can help
Chiropractic claims require more explicit accounting practices than other more traditional medical claims, and mistakes can lead to headaches when having to deal with insurance companies that are hesitant to cover services.
ChiroFusion is a full-service chiropractic billing services company. We handle the entire revenue cycle, from claims processing and submission to denial management and payment follow-ups. Our billing service works in conjunction with our award-winning electronic medical records software and practice management platform. Learn more about our chiropractic billing services and how we can increase your profitability by up to 20%.