Medicare processes hundreds of millions of claims each year. Our client service team deals with billing and Medicare claims issues daily for our own policyholders. Because of this, our team members have become masters in handling denied Medicare claims and have learned a lot about them.
Medicare does deny some claims. Since Medicare has so many billing rules and requirements, medical billing staffs aren’t always aware of how to bill a particular service. This can result in claims denials and Medicare can also deny claims for other reasons.
Knowing why Medicare denies claims can give you a better chance at avoiding the problem altogether.
Coding errors can result in denied Medicare claims
Medicare has an assigned Healthcare Common Procedure Coding System (HCPCS) code for each medical service. If the HCPCS code the doctor’s billing staff uses is incorrect in any way, Medicare may deny the claim. A service commonly affected by coding errors is the Welcome to Medicare visit.
The Welcome to Medicare visit is a preventive service Medicare covers at 100% within the first 12 months a beneficiary has Part B. However, if the code reflects a normal checkup, rather then the covered wellness visit, Medicare won’t cover the visit at 100%, which results in unnecessary bills to you. This is called a procedural code error.
Another type of coding error that can cause the claim to be denied is a diagnostic code error. There are certain services and procedures that Medicare only covers if the patient has a certain diagnosis.
If the doctor’s billing staff codes the procedure correctly, but fails to give Medicare the correct coding information for the diagnosis, Medicare may deny the claim. Lack of appropriate diagnostic codes is one of the most common forms of coding errors the Boomer Benefits client service team handles for our policyholders.
Lack of medical necessity can result in denied Medicare claims
Medicare does not cover anything that isn’t considered medically necessary to treat or diagnose an illness or condition. Doctors have been known to phish for a diagnosis by completing several services without having a solid reason to do so. In hopes to eliminate this, Medicare requires doctors to prove medical necessity for each service they provide their patients.
On the other hand, doctors may provide services they think the patient needs. Medicare doesn’t agree and it denies the claim because the doctor didn’t prove medical necessity. A service that is often denied for this reason is blood work.
Doctors grow accustomed to non-Medicare insurance, which usually covers blood work. So, when they have a Medicare patient, they think routine blood work will be covered. However, that’s often not the case. There needs to be a definitive reason for the patient to receive any kind of blood work. If that reason isn’t represented to Medicare, the claim will be denied.
Medicare also won’t cover blood work when it’s done as part of the Welcome to Medicare visit. Doctors sometimes don’t think about this and will order blood work during the Welcome to Medicare visit.
This blood work is diagnostic and will often be processed as an ordinary claim. Then you owe 20% of the cost unless you have a Medigap plan covering that for you. You might not be expecting that and then you are surprised when a bill arrives in your mailbox.
Advanced Beneficiary Notice of Non-Coverage
If a provider recommends a service that he or she Medicare won’t cover, the provider must hand the patient an Advantage Beneficiary Notice of Non-Coverage (ABN). An ABN officially informs you that Medicare might not cover the claim. It also states if the service is indeed denied by Medicare, the patient agrees to pay the non-covered charges.
When your doctor gives you an ABN, you can choose to sign it and receive the service, or you can choose not to sign it and forego the service in question. Receiving an ABN doesn’t mean the service won’t be covered. It simply means that Medicare may not cover the service. Providers are not required to offer an ABN for services that Medicare never covers, like cosmetic procedures.
An example of when an ABN is often handed out is before an ambulance ride. Medicare only covers ambulance rides when they are medically necessary and met certain requirements. If the ambulance provider doesn’t believe all necessary criteria are met for the ride, they will hand the patient an ABN before the ride.
Coordination of benefits issues can result in denied Medicare claims
Medicare has a Coordination of Benefits (COB) department that manages claims when you have other insurance, such as through an employer. It determines which insurance plan pays primary and which pays secondary. For example, if someone has large employer coverage and Medicare, his employer plan pays primary and his Medicare pays secondary. Claims are paid accordingly.
When a beneficiary drops employer coverage and transitions to Medicare, the employer should notify Medicare. Then Medicare updates their database to show they are now the primary payer. However, sometimes the employer fails to transmit this information correctly or at all.
A COB issue then often occurs when a patient goes to the doctor for the first time since retiring and switching over to Medicare as primary coverage. The doctor bills Medicare, but because Medicare still shows to be the secondary payer, they deny the claim. Because this is such a common issue, Medicare has a line dedicated to updating beneficiary’s COB. Our client service team here are Boomer Benefits can assist with claims rejections that result from this at no cost to our clients.
Non-covered services result in denied Medicare claims
There are some services Medicare simply doesn’t cover. Routine dental, hearing, and vision exams are all examples of non-covered services. Medicare denies these services unless they are proven to be medically necessary to treat a medical condition. For instance, Medicare may cover a dental exam if the patient is about to undergo an organ transplant.
Because Medicare rarely covers any of these services, you will need a dental, vision, and hearing plan. We offer a DVH plan here at Boomer Benefits. Many Medicare Advantage plans offer dental, vision, and hearing benefits as well.
Denied claims are no fun
Denied claims can be a pain to deal with. Instead of trying to figure out why Medicare denied a claim by yourself, let our client service team assist you. Our legendary client service team will be able to find out why Medicare denied the claim. They will help the provider resubmit the claim if necessary. If Medicare should have covered the claim, our team can often straighten it out for you. This often saves our clients hours of time and hassle in tracking down the problem. We conference in the right people to assist you with straightening things out.
There is no charge to use our services. Call us today to find out how to become a Boomer Benefits client.