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4 tips help avert insurance denials
By Brent Detelich, DC
How many times have you received an insurance company’s EOB (explanation of benefits) with the denial, “not medically necessary”?
This ambiguous denial rationale is often repeated when you resubmit the bill — even when you include copies of office notes and treatment plans. This repeated pattern is one of the most frustrating problems facing us.
The problem has several different causes:
Computers find “red flags,”
Inappropriate codes are used on claims,
Claims do not show goals based on medical necessity, and
Claims do not contain justification for ongoing treatment.
To avoid having your claims kicked back, here are some tips to follow:
1. Narrow your scope of diagnosis. The average chiropractor has a few favorite diagnoses that he or she uses over and again. Using these same 10 or 20 codes waves a red flag at the computer and causes it to spit out denials. Instead, narrow your diagnosis and be specific. Doing this will actually increase the number of diagnostic codes you use.
Functional testing rationale
|Functional tests help establish evidence of medical necessity, the basis for reimbursements. Apply functional testing (and document the results):
• As soon as the patient is out of acute pain,
• To establish a baseline from which to monitor the efficacy of an active care program,
• To show objective data or “proof” of functional restoration,
• To document the achievement of the treatment goals,
• To establish the need for a change in the treatment phase of care, and
• To show maximum medical improvement and any permanent disability.
2. Select appropriate codes. Some diagnoses, such as treatment for pain, by their nature have a limited period of medical necessity. If your diagnosis does not show a degree of complexity, the claim will be denied, regardless of the documentation you provide.
3. Measure functional and range of motion losses. All physical medicine guidelines contain two common themes — function and motion. These are also referred to as strength, endurance, range of motion (ROM), activities of daily living, etc.
At the beginning of treatment, objectively document functional and range of motion (ROM) losses, then monitor improvement as the patient achieves goals.
An automated ROM/MM testing system that prints reports based on the AMA guidelines is invaluable. The information provided in these reports is crucial to justifying care to insurance companies. Choose a system that prints easily read graphs that clearly demonstrate the patient’s improvement at a glance.
4. Write clear goals and update them regularly. The goals need to establish medical rationale for the case. Claims are denied when clear goals and a plan for accomplishing them are not provided.
The most successful approach to documenting a care plan is to outline goals for functional restoration and range of motion improvement. Set these goals in easy-to-achieve increments and move on to the next set of goals and corresponding treatment when the first goals are achieved. (See sidebar, “Setting reasonable goals.”) When you are dealing with an insurance company’s review department; a glance is all the claim gets. That glance must quickly demonstrate:
The patient has a deficit,
The deficit has improved with treatment, and
Ongoing care can still improve the patient’s functionality and motion.
If you use this process of appropriate diagnoses and treatment goals, documenting attainment of those goals and demonstrating the need for continued care, denials based on “no medical necessity” will decrease dramatically.