Empowering your medical practice for success
Nick van Terheyden, M.D., was very familiar with claim denials and rejections.
As a former emergency department physician from the U.K., he knew payers frequently withheld or reduced payments. However, it wasn’t until his own insurance company, Cigna, denied his personal medical claim for a vitamin D test that he decided to explore the issue more deeply.
“I struggled to understand how Cigna could come to this decision when the physician reviewer knew very little about me,” he recalls. van Terheyden had been complaining of severe pain in his hips and acetabulum, and his physician suspected he might have vitamin D deficiency.
van Terheyden followed the payer’s instructions to appeal the denial, and Cigna upheld the original decision. It wasn’t until he pursued an independent external review that Cigna overturned the denial. The reviewer concluded the test was medically necessary as indicated by the severe bone pain and because it revealed a vitamin D deficiency that put van Terheyden at risk for bone fracture without supplementation.
van Terheyden worked with an investigative reporter from ProPublica who ultimately discovered that his claim was one of approximately 60,000 that the same reviewer had denied in a two-month period. Interviews with two former Cigna physicians confirmed that the company uses an algorithm to flag mismatches between diagnoses and tests or procedures and then company physicians simply sign off on denials in batches, without ever looking at any medical records. (To read the investigative story, visit https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims).
“Physicians come into work every day trying to deliver the best possible care to patients,” van Terheyden says. “They make good clinical decisions and then get denied. That’s very disconcerting.”
Outsmart payer algorithms
Although ProPublica’s story focuses on Cigna, the massive volumes of denials are not exclusive to one payer, according to Toni Elhoms, CCS, CPC, CPMA, CRC, who is CEO of Alpha Coding Experts LLC in Orlando, Florida. Elhoms says she has seen an uptick in all payer denials over time largely due to the increased reliance on algorithms and artificial intelligence.
“I always tell providers to flood payers with peer-reviewed literature saying why something is medically necessary,” Elhoms says. “Your appeal letter must support your position and why you’re appealing the denial. Very often, payers are wrong.”
Medical practices may not even know a payer has denied a claim unless they check the claim status through the payer portal, according to Katie Nunn, MBA, CMPE, a practice management consultant in Richmond, Virginia. “Most payers are banking on you not doing this,” she says. “Payers are smart enough to know whether you’re going to work your A/R (accounts receivable) or not. You could be taken advantage of.”
Another strategy to combat algorithms is to link the test or procedure with the diagnosis that most accurately reflects the reason for that test or procedure. Many payer algorithms aren’t sophisticated enough to look beyond the first-listed diagnosis code, Elhoms says. Taking this extra step to link the codes may not prevent the denial in every instance, but it will certainly mitigate risk, she adds.
Avoid denials related to modifier 25
The ProPublica story comes on the heels of Cigna’s announcement that it will prescreen claims with Current Procedural Terminology code modifier 25 prior to payment beginning May 25, 2023. “This is going to hurt small, independent practices,” Elhoms says. “Physicians won’t get paid until they go above and beyond to submit documentation.”
Elhoms’ bigt fear? A three-week turnaround time for payment could easily turn into three months or more. “It’s going to be a nightmare during vaccine season when physicians start to bill flu shots with the annual wellness visit or chronic care management,” she says.
Elhoms’ other big fear? Other payers will eventually follow suit. “I think this will spread like wildfire,” Elhoms says. “UHC (United Healthcare) and Anthem already tried to implement this policy but eventually rescinded due to industry pushback. This policy allows for significant cost savings on the payer side.”
Elhoms provides these three tips to help physicians navigate the Cigna policy once it takes effect:
Hire an external auditor. “It’s not enough to think you’re compliant,” Elhoms says. “You need to validate your data.”
Provide education. Based on the results of this audit, practices may need to provide physician and staff education, according to Elhoms.
Create a modifier 25 workflow. All claims with modifier 25 should route to a dedicated staff member charged with submitting necessary documentation, according
The Cigna policy only complicates what is already a difficult process across all payers: applying modifier 25 correctly, according to Rhonda Buckholtz, CPC, CPMA, owner of Coding and Reimbursement Experts in Pittsburgh, Pennsylvania. The process became even more challenging when new evaluation and management (E/M) guidelines took effect on Jan. 1, 2021. “Now codes are based solely on medical decision-making, and physicians really need to be able to carve procedures and services out separately,” she says.
Buckholtz says she sees denials most frequently when physicians bill a Medicare annual wellness visit and E/M code with a chronic condition diagnosis code. “The wellness exam includes a review of current medications, so unless there is a new problem or a significant health change, most often the levels billed are not supported by documentation,” she says.
Ensure diagnosis code specificity
Another big area of concern for small, independent practices is payer scrutiny of diagnosis codes, according to Buckholtz. “There are payer edits out there that match the diagnosis code with the level of service you bill. If you use an unspecified code, sometimes the payer is downcoding you a whole level,” she adds.
This is particularly true when physicians use an unspecified diagnosis code as a first-listed code. However, it also occurs when physicians report unspecified hierarchical condition category (HCC) codes to Medicare Advantage and commercial plans, according to Buckholtz.
Buckholtz provides this example: A patient presents with hypertension and chronic kidney disease (CKD). If the provider looks in the electronic health record (EHR), they’ll see a code for hypertension and one for CKD. However, rather than reporting two separate codes, International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) guidelines state providers must report a combination code and an additional code to specify the stage of CKD. “These codes do hit risk adjustment, and providers could fail a risk adjustment audit if not captured correctly,” she says.
Buckholtz provides this advice:
Run a report of the practice’s top 20 diagnosis codes. Look at the specificity of those codes. How often and for what diagnoses do unspecified codes appear?
Update EHR drop-down menus to include more specific codes if necessary.
Use “other specified” codes when appropriate.
Review ICD-10-CM coding guidelines to prevent overlooking combination codes and specific coding rules.
Ask payers for feedback on HCCs. Medicare Advantage plans should be able to provide this information because they undergo federal risk adjustment audits.
Verify insurance eligibility
Claim rejections frequently occur when providers don’t take the time to verify the patient’s insurance coverage, according to Mary Pat Whaley, FACMPE, CPC, founder and president of Manage My Practice in Durham, North Carolina. “Everyone struggles to identify what plan the patient has,” she says. “Patients are often just as confused.”
Experts provide three critical strategies:
Ramp up eligibility efforts at the beginning of the year. That’s when plans typically change. Leverage real-time eligibility checks and provide staff education. Also, leverage the patient portal and check-in kiosks to promote a more streamlined process that relies on patients’ self-reported information, according to Nunn.
Always check the patient’s insurance card and verify their plan(s). Patients don’t always know whether they have a Medicare Advantage plan or a supplement plan to Original Medicare, according to Whaley. Many commercial plans offer both. “Most practices are enrolled with Medicare but may not take the Advantage plans, so this is a big source of denials,” she says.
Be mindful of the Medicaid redetermination process. Patients who previously qualified for Medicaid during the COVID-19 public health emergency may no longer qualify, and they may have switched plans.