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Reimbursement Tips
Top Reasons Claims Are Denied
According to the Medical Group Management Association (MGMA), the 5 most common reasons for claim denial are:
- Diagnosis is not coded to the highest level of specificity
- Missing patient subscriber or ID number
- Patient name and/or address doesn't match insurer's records
- Missing physician information or ID number
- Claim information is illegible or improperly entered
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Tips for Appealing a Denied Claim
These simple steps can get your claim back on track:
- Review your claim and be sure all the required fields are complete and correctly coded
- Carefully read the explanation of benefits to understand exactly why the claim was denied
- Submit to the payer a formal letter of appeal contesting the denial
- Contact the payer's office if a response is not received in a timely manner
- Utilize the Bayer HealthCare Pharmaceuticals Reimbursement Support Line
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Physician Office Reimbursement Survival Check List
Medicare reimbursement changes can have a significant financial effect on your practice. Here's what you can do to help keep your practice fiscally fit and healthy.
Assess how changes in chemotherapy regimens and supportive-care drugs are affecting your practice
Review billing systems
— Validate 3-digit unit-billing capabilities to accommodate new and updated J-codes
Update charge master and superbills
— Medicare pays "lesser of the charge"
— Allow for new coding scenarios
Review co-payment collection procedures
— Identify patients without a Medicare supplement
— Verify that secondary claims are submitted to payers when appropriate
Train staff on new coding requirements
— Office visit vs therapeutic injection administration
— Correct billing for multiple chemotherapy pushes
Make sure all appropriate charges are captured
— Appoint an audit team to assess:
- E & M codes and appropriate documentation
- Lab CPT codes
- Multiple chemotherapy pushes
- ABNs
Identify ways to enhance practice revenue through operational and service functions
— Nutritional and counseling services
— Ancillary services
— Pharmacy services
— Clinical trials
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