ob-gyn claim denials appealing strategies

 Erika Regulsky Tags: , , Coding, Compliance, RCM
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Who gets the upper hand?

Denials are a thorn in the flesh for most medical practices. But there are some specialties that have an exceptionally high denial rate. Obgyn is unfortunately one of them. Denial rates in this specialty are the highest at a whopping 22.42%. Denials are an everyday occurrence for most obgyn centers. But that doesn’t mean you need to live with them. Most denials are “soft” and with some effort be easily overturned. The cost of handling a denied claim is on an average $25. It considerably adds up to the administrative and financial burden of a practice.

Recently BiIlingParadise worked with an ob-gyn practice that was facing a financial slump. Upon analysis, we found that their previous biller had no experience in billing for antepartum codes and also repeatedly missed adding Modifier QW for screening services. This led to a high number of denials and a steep downturn in revenue for the ob-gyn practice. The appealing process was extremely tough given that most claims were also way beyond the timely filing limit. This story does have a happy ending. We managed to increase the revenue of the ob-gyn center by 60% within a few months.

“Become claim status investigators” 

There are so many facets to appealing a denied claim. While each denial may seem the same, each one is definitely unique. I tell my staff that they are CSI agents. (Claim Status Investigators). The first thing I do when a claim is denied is to review the EOB and determine why it was denied.

While this may seem Elementary, I have reviewed too many providers AR where nobody has done anything on the claim and they just resubmit the claim without reviewing why it was denied, or send in an appeal with records when they just needed a diagnosis change, Etc. So the first thing in your CSI investigation is to figure out why the claim was denied and then work backwards how to fix it.

“Winning appeal always involves solid payor policy research”

It is critical to follow the appeals process laid out by the payor. Never assume payor appeals processes are identical. Mark the dates for deadlines and plan on sending appeals 4 -5 days before a deadline. Repeat this for each level of appeal. A winning appeal always involves solid payor policy research, supplying complete medical records (with Orders, Lab Results, XRay Reports, the works, to ensure medical necessity), and crafting a well-written appeal letter addressing the denial reasons while providing strong details of support from the documentation.

I’ve had success in the amounts of small monies to tens of thousands to complete overturning and complete winning resolutions for a vast array of providers over my ten years in this field. These strategies, as well as solid writing and researching skills, have proven to be successful for me.

So what happens when you are hit by the big “D”? This article I came across recently gives some practical simple tips to appeal denied claims
If you are interested in reading the entire case study click here.

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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

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