Wrongful Payer Denials: How to Handle Them Quickly

January 23, 2016 | By: P.J. Cloud-Moulds (Original Post)

Something interesting happened last week that I wanted to share with you all. There is a local managed care HMO plan that started to wrongfully deny all new patient evaluations stating the claims were denied for: “Medicare Evaluation Codes with no functional G-codes.” Yes, in an HMO, managed care plan that has nothing to do with Medicare whatsoever. I stared at the denials in disbelief. I was dumbfounded, and just thought, “This must be a mistake. I’ll call them up and see what they say.”

Multiple calls were made by a few of the staff and the same answer was provided; that all of the evaluation codes require a functional G-code attached to it. There were multiple requests to speak with supervisors, as this plan is not tied to Medicare at all. We kept receiving the same information, as more denials rolled in.

We looked back and found this plan started denying these claims back in October, and since it takes them 60 days to 90 days to process claims, we’re just now starting to receive these.
I looked back through all of the documentation we received from them, I reviewed all of the Medicare rules and who they apply to, and I went to the plan’s website to see if the provider manual had been updated without our knowledge. I even pulled the contract to see if any addendums were made that we did not sign off on. It was a treasure hunt for information.

Once our billing department exhausted all of these potential solutions and we were getting nowhere with representatives reading from canned responses on their screens, we took it to the next level. We found a resource who used to be the CEO of this plan and ran these denial reasons by him. He laughed and said, “No! They cannot ask you to go back now and change a patient’s medical record.” Since there wasn’t any correspondence back in October letting us know this was something they were going to require, this was going against all contract regulations.

We were able to then contact the current CEO of the plan, unfortunately, she did not even understand what we were asking her. It was sad, really, that something so unscrupulous was going on under her nose, and she had no idea. When she conferred with a staff member there at the plan, they backpedaled saying they were looking for a specific modifier, not Medicare G-codes. So, we gathered up every denial that we had, put them into a large envelope and drove them out to her office. Shockingly, she had left for the day and was unavailable.

We followed up earlier this week, and humbled as she was, she said she would look into it and override the system that was causing the denials. She promised to cut us a check for wrongful denials due to this specific code. We then asked for interest on late payments. Although we all know it’s just a few pennies, it’s the principal of the matter — insurance companies are getting more and more arrogant with their denials and need to be held accountable.  It also makes me wonder how many other local providers are having the same trouble, but just make the denial adjustment, and don’t follow up.

Because this was a local plan in the Southern California region, this method worked out well for us. We certainly still have the option to create a claim with the department of managed care so they can look further into this activity. However, if this were a Blue Cross Blue Shield or Aetna-type plan, the method would certainly be very different. But I would still most definitely fight the denial. Without specific contract changes that the owner must sign, making significant changes to your contract like this is illegal.

Most states have a governing agency that does monitor complaints from patients and providers against insurance companies. Locate yours and have that contact information on hand. Obviously, it is up to you and the resources you have available, but if you believe you are being wrongfully denied, by all means speak up! Chances are, if you’re being denied, a fellow provider is as well.

Set Your ICD-10 Goals for 2016

[ By Avery Hurt, December 2015 | See original page ]

The ICD-10 transition will continue into the next year for practices. Here are some tips you’ll need to take in 2016.

ICD-10 has gone pretty smoothly so far, but savvy practices are planning their ICD-10 goals for 2016.   Fletcher Lance, vice president and national healthcare leader at consulting firm North Highland, pointed out that while some of what we were worried about in the lead-up to the ICD-10 transition did come true (a 25-30 percent drop in coder productivity, for example), some didn’t (so far, only a roughly 2-4 percent increase in denials). “Everyone, understandably, has breathed a sigh of relief, but it’s not time to take your hand off the wheel,” said Lance. We can expect denials to continue to increase—even if gradually—as payers tighten up on specificity requirements. Lance also pointed out that there are still a lot of claims in the system that haven’t made the loop yet.

Elizabeth Woodcock, president of Woodcock and Associates, an Atlanta-based physician practice consulting firm, agreed. “My concern is that right now payers are adjudicating pretty much everything that makes sense. When they start tightening up in the next 9-18 months, then we’ll start to feel the squeeze.” Practices shouldn’t expect a “tsunami of denials,” said Lance, but something more like “denial creep.” Nonetheless it is something practices ignore at their peril. Woodcock expects that the tightening will first occur in the area of pre-authorizations and pre-certification requirements.

It’s not just getting the codes right that practices need to be preparing for in 2016. “Once enough data is collected,” said Tammie Olson of Management Resource Group, a firm offering financial management and support services for the healthcare community, “payment policies are likely to change. Conditions that were covered before may not be covered any longer.” If you want ICD-10 to go at least as smoothly in 2016 as it as so far, here are a few steps you need to take:

* Make sure you have the financial cushion to cover a potential increase in denials—especially if your coding isn’t totally up to par and you’ve been counting on leniency from payers.

* Track denials and work them in a timely manner.

* Continue to train coders — advanced classes and classes for specialties are available. Address any drop in coder productivity.

* Woodcock recommends designating one biller who sets aside a few hours each month to check for policy changes on the websites of every major payer. Changes will be posted on websites, and if you don’t look for them, you won’t know about them.

“Remember that ICD-10 may have been implemented Oct. 1, 2015, but the impact will continue,” said Olson. “Just because things have been smooth so far doesn’t mean that changes aren’t going to come in the future.” On the other hand, Lance sees plenty of reason to be optimistic. “Sometime in the next year or so, we’ll start to see how we can use this data for better patient outcomes.” And that’s why we did all this, wasn’t it?

For Practices, the ICD-10 Rollercoaster Has Just Begun

Date: October 15, 2015 | By: Stacie Bon

ICD-10 is finally here! After more than a decade of discussion, delays, and planning, the ICD-10 implementation deadline has officially arrived. Physician practices will now see whether their ICD-10 preparations are adequate, in need of some fine-tuning, or require a complete overhaul.

Even the most thoroughly prepared organizations are likely to experience some steep hills and deep valleys during the early days of ICD-10 usage. In fact, CMS predicts that claim error rates will be more than two times higher with ICD-10, reaching a high of 6 percent to 10 percent in comparison to the 3 percent average using ICD-9 codes. CMS is also predicting that denial rates will rise by 100 percent to 200 percent and days in accounts receivable (A/R) will grow by 20 percent to 40 percent.

To thrive in the ICD-10 environment, physician practices need greater transparency into their revenue cycle. One way organizations can achieve higher levels of transparency is through the use of comparative analytics, which organize and analyze revenue cycle data, create benchmarks, and define actionable insights. For example, using comparative analytics, a physician practice can identify the root cause of revenue cycle issues, correct the issues, and minimize or avoid their impact entirely.

Comparative analytics can provide practices with a comprehensive view into their data and organize the data to guide them as they create benchmarks, assess business impact, and identify trends related to ICD-10 implementation in the following areas:

• Claim denial rates
• Denial reasons
• Deviations in coding and claim types
• Staff productivity
• Payer performance
• Compliance
• Utilization

Leveraging internal and external data on a state and national level provides a baseline for organizations to better understand where they stand compared to the industry and their peers. This additional layer of data helps inform physician practices of actions they need to take and also helps them prioritize their initiatives based on achieving the greatest return on investment.

Creating Benchmarks

A big concern with the switch to ICD-10 is a practice’s ability to achieve revenue neutrality. In essence, will practices generate roughly the same reimbursement with ICD-10 as they did with ICD-9? Benchmarking capabilities within comparative analytics software can provide insights to answer questions like this.

Benchmarking enables practices to analyze historical ICD-9 claim payments and compare them to equivalent claims that utilize ICD-10. Findings from the analysis can help identify business issues. For example, do coding processes need modification? To further assess the impact of ICD-10, practices have the ability to identify their current high-dollar or high-volume diagnoses and answer the following questions:

• Have our high-dollar or high-volume diagnoses changed with ICD-10?
• Is revenue and/or diagnoses changes related to ICD-10 coding or changes in patient case mix?

There is also value in benchmarking the before and after impact of ICD-10 implementation, across multiple areas of the business, such as:
Billing staff productivity.  Are new processes or staffing changes impeding productivity?
Claims denial rates. Are your denials the result of payer errors, billing staff errors, or medical necessity edits?
Payment turnaround times. Are payers experiencing payment backlogs?
Reimbursement. Is your organization receiving the full amount of reimbursement that it is entitled to?

And most importantly, are your peers experiencing similar results? If not, how do you explain the differences and where do you need to prioritize your focus?

A visit to the amusement park can be fun, but most businesses don’t want their revenue cycle to experience the ups and downs of a roller coaster. Comparative analytics can provide the transparency — or insights — that allow physician practices to see what is ahead and what is behind them.

How to survive the ICD-10 transition if you’re just starting

With less than 30 days until the ICD-10 deadline, physician practices better be ready to use ICD-10 codes. If not, get started.

With that timetable in mind, I cribbed and put into a post the Centers for Medicare and Medicaid Services (CMS) ABCs of ICD-10 preparation. There are three parts to it:

  • Assess how ICD-10 will affect your practice and make a plan
  • Be sure your systems are ready
  • Contact your vendors

Considering I’ve been blogging about this for four years, that doesn’t seem like a lot of work. Denny Flint, a healthcare consultant, sees advice like this as too much work. Not that he’s against hard work, but there isn’t enough time to do a lot of ICD-10 project planning. So he strips it down to clinical documentation training.

Even that is pretty easy in his opinion. Start dual coding patient encounters. He calls it a silver bullet. Dual coding will show where documentation falls short and give the coding staff practice with the ICD-10 code set.

Rosemarie Nelson suggests a similar quick path to ICD-10 implementation but points out something that needs to be added to Flint’s advice: Focus on the most common diagnoses.

Flint also recommends dual coding at least 10 patient encounters each week. Make sure the most common diagnoses are part of that mix. If you don’t have a practice management system that can run a report of common diagnoses or ICD-9 codes, the look at the superbill. Go by instinct or memory. But start coding something.

Countdown to ICD-10

The MLN Connects Provider eNews for Sept. 3 provided links to several ICD-10 resources:

(Centers for Medicare and Medicaid Services)

Your last-minute guide to prepping for ICD-10

  1. Contact your vendors
  2. Train your staff
  3. Convert your top 10-15 diagnoses to ICD-10 codes
  4. Prepare to watch acknowledgement reports
  5. Reserve cash

(AMA Wire)

6 Tips to Reduce Productivity Loss with ICD-10

  1. Medical coder training
  2. Physician training
  3. Convert forms and templates to ICD-10 codes
  4. Test with payers
  5. Clean up your billing back logs
  6. Automation can  boost productivity


ICD-10 readiness: shaky optimism

Looks at a survey by Porter Research in August and commissioned by Navicure:

  • 85 percent were optimistic they would be ready Oct. 1.
  • At the time of the survey, 57 percent said they were ready.
    • Thus, the “shaky optimism”
  • Note, other surveys found much less readiness among smaller healthcare providers.
  • Healthcare providers worry about:
    • Cash flow
    • Staff morale
    • Clinical documentation
    • Patient experience
    • Staff productivity

(Healthcare IT News)

Laterality, Anatomical Specificity Important In ICD-10 Oncology Codes

  • Breast cancer: Document where cancer appears in the breast and which one (left or right).
  • Benign neoplasm of the colon, rectum, anus, and anal canal: Be specific about where in the colon it occurs.
  • Sickle cell anemia: This is now a combination code.
  • Primary liver cancer: Specify the type of liver cancer.
  • Lymphoma: There will be many types of lymphoma to document as well as anatomical location.
  • Malignancy in pregnancy: Coding goes beyond the neoplasm chapter. For example, you will need to document trimester.


Live CEU Webinar – ICD-10: Last Minute Tips for October 1st

I don’t usually recommend webinars but I thought one on last minute ICD-10 tips scheduled for Sept. 22 is aptly named. (Daily Practice Blog)

ICD-10 tools continue trickling to market

  • CureMD unwrapped a free training tool for physicians.
  • NueMD posted ICD-10 tools that include a code-search function and training games.
  • ICD-10 Charts posted free online services for converting from ICD-9 to ICD-10 and building charts with ICD-10 codes.
  • 3M Health Information Systems updated its cloud-based Code Translation Tool for converting ICD-9, CPT or HCPCS codes into ICD-10 as well as normalizing reports, updating processes and educating staff.

(Healthcare IT News)

ICD-10 financial impact update

Grab a cup of coffee before you get into this financial analysis of how ICD-10 coding will affect MS-DRG reimbursements. The bottom line is that  reimbursements will drop less than 1 percent after Oct. 1. (3M HIS Blog)

ICD-10: 5 Ways to Prepare for the Home Stretch

Blog | September 19, 2015 | ICD-10, Operations, Staff By Pam Klugman

After much talk and maddening delays, less than 21 days remain before ICD-10 takes effect.

Over the past year, medical groups and individual physicians have been working — some methodically, some scrambling — to get ready. Staff has been trained, technology has been upgraded, myths have been dispelled, and practice runs have taken place. But now is no time to take your foot off the accelerator: The stakes are simply too high.

As physicians head into the final home stretch, here are five things to do between now and September 30 to help ensure a successful transition to ICD-10:

  1. Remember the changes brought about by ICD-10 will have an impact on everything within the medical office. Don’t fall into the trap of being too limited in who you train or in underestimating its implications. Make sure you have trained the front-office staff; clinical staff; billers and coders; and, of course, physicians. So, too, remember that everyone will need to use ICD-10 codes for any procedures performed on or after Oct. 1. You won’t get paid for any claims of services if you continue to use ICD-9 codes.
  2. By now, you should have compiled a list of your practice’s 50 to100 most common ICD-9 codes and mapped them to their, often numerous, equivalents in ICD-10. You should have also started working with the codes to become familiar with them and thus avoid the stress of learning new code structures after ICD-10 has taken effect and your cash flow is directly impacted. If you haven’t done so already, now is your last chance to test not only the knowledge of your office staff, but the technology you have in place to make sure it can generate a claim, perform eligibility and benefits verification, schedule an office visit, schedule an outpatient procedure, update a patients history, and code a patient encounter. Test, test, and test again.
  3. These final days are your last chance to make sure your vendors and health plans are just as prepared as you are. Talk with any software vendors, clearinghouses, or billing services you use to be sure they are ready to provide the support you need and then test your system with partners you work with most often. Remember, ICD-10 means much higher data-management demands thanks to larger procedure and diagnosis code sets, so it is not only critical to make sure your own practice management software can handle this changeover, but your vendors’ staff and IT systems can handle this increased capacity as well.
  4. If you don’t feel fully confident you will be ready on Oct. 1, there are a few things you can do. First, take advantage of the free events and training sessions offered by CMS to help practices prepare for ICD-10. Check the CMS events calendar for details. Medical societies and healthcare professional organizations are also great resources for knowledge and support. So, too, turn to vendors you trust to be your partner in navigating your way through this conversion. Second, explore alternative ways to submit claims to health plans if you feel your systems won’t be ready for the changeover. For Medicare providers, options might include free billing software or even paper claims for providers who meet the Administrative Simplification Compliance Act Waiver. Third, you may want to consider securing an additional line of credit to ease the impact of delayed payments on cash flow and operations.
  5. The most important thing you can do is keep your cool. Change of any kind, even good change, carries with it a certain amount of anxiety. Even for those practices best prepared, this conversion will be complicated and at times frustrating. After all, the move to ICD-10 will drastically impact how physicians around the country are paid as well as how the care they provide to their patients gets captured and reported. ICD-10 includes more than 68,000 diagnostic codes, compared to 13,000 in ICD-9 while including twice as many categories and alphanumeric classifications for the first time. The new codes include fundamental differences such as changes in terminology and a greater level of diagnosis detail to appropriately reflect advances in medical knowledge. These are some of the most important transformations ever in the healthcare industry. The degree and complexity of these changes underscores the need for physician groups to have the right tools, knowledge, people, and foresight in place … but it also should remind you to be thoughtful and supportive of those in your office working hard to meet this challenge.

Approaching the ICD-10 Implementation with Confidence

Date: July 24, 2015 | By: Mary Jean Sage

Here are 11 tips to ensure your practice will be on track for a successful ICD-10 transition come Oct. 1, 2015 and beyond.

The deadline for implementing ICD-10 is rapidly approaching.  Providers and practices should be preparing for the transition and approaching the implementation with confidence. They should be doing this even with the recent announcement from CMS on creating a one-year grace period, allowing for flexibility in the claims auditing and quality reporting process during the transition.  Addressing the following 11 steps will help assure your practice will be on track for a successful transition on Oct. 1, 2015 and going forward:


Review the major differences between ICD-9 and ICD-10 and how those differences will affect a clinician’s specialty as well as your organization as a whole. Reviewing the “Official Guidelines for Coding and Reporting” for ICD-10 is a good starting point.


Include staff from the administrative and clinical sides of your practice and divide up the work that needs to be accomplished. Make sure you communicate the changes required by ICD-10, both from a workflow standpoint as well as clinical documentation.


Consider all the different systems you use, the organizations you exchange data with, as well as what electronic and paper-based workflow processes you use that drive clinical encounters and the billing process.  Make sure all of these are updated and/or modified appropriately for ICD-10 compatibility.


Ask vendors about any needed upgrades to use ICD-10, what training (if any) will be needed, and cost estimates. Don’t forget to ask about the ability to concurrently use ICD-9 and ICD-10 and how long you’ll have the ability to do that.


Make sure you consider software and hardware upgrades, education and training costs, the cost of temporary staff during transition should it be needed, changes to printed materials, additional time for documentation review, and the cost of lost coder, clinical and/or revenue cycle staff productivity.


Ask if all their upgrades to accommodate ICD-10 have been completed and if they haven’t, when they will be. Also ask how they (the clearinghouse and health plans) will help your practice with the transition, when can you test claims and other transitions with ICD-10 codes, and whether they provide a list of any data content changes needed. Don’t forget to ask the health plans when they expect to announce their revised ICD-10-related coverage/payment changes.


This may be one of the most challenging aspects of ICD-10.  Identify potential documentation issues by beginning to crosswalk ICD-9 codes to ICD-10 codes. The goal should be to identify any gaps in the documentation that prevent a coder from selecting the appropriate ICD-10 code.


Identify your education needs. While everyone will need to be trained, not everyone will need to be trained at the same level. Identify who should be trained on what.  You will also need to identify the best training mode for each group and the timeframe for providing that training.


Testing is critical to success with implementation.  Plan for both internal and external testing.  This will need to be scheduled, so begin the planning now.


Every practice needs to plan for decreased staff productivity and prepare for the possibilities of other financial challenges during the initial implementation period. You should set aside some cash reserves for the practice. It may also be wise to consider establishing a line of credit.

Preparing now for the transition to ICD-10 will help ease the burden of compliance on Oct. 1, 2015 and assure you will not have a major disruption in your practice revenue.


Make sure you familiarize yourself with the new grace period rules, including some key points below. CMS also announced the establishment of a communication center and an ICD-10 ombudsman to help receive and triage physician and provider issues.

Medicare contractors will not deny claims based solely on the specificity of the ICD-10 diagnosis code as long as a valid code from the right family of ICD-10 codes is used. Moreover, physicians will not be subject to audits as a result of ICD-10 coding mistakes during this one-year period.

Physicians will not be penalized under the various CMS quality reporting programs for errors related to the additional specificity of the ICD-10 codes, again as long as a valid ICD-10 code from the right family of codes is used.

If Medicare contractors are unable to process claims within established time limits because of ICD-10 administrative problems, such as contractor system malfunction or implementation problems, CMS may in some cases authorize advance payments to physicians.