Denial Management & Appeals Flashcards
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Read the first 7 Denial Management & Appeals flashcards as text
What is the primary goal of tracking a practice's denial rate as a key performance indicator (KPI)?
Answer: To measure the percentage of claims denied and identify trends to reduce future denials
Monitoring the denial rate helps practices identify patterns in denials, address root causes, and implement process improvements to reduce revenue loss.
Which of the following actions best prevents 'authorization not obtained' denials?
Answer: Verifying and obtaining prior authorization before services are rendered
Proactively verifying prior authorization requirements and obtaining approval before rendering services is the most effective prevention for authorization-related denials.
A claim is denied because the rendering provider's NPI is not on file with the payer. What should the biller do?
Answer: Contact the payer to credential/enroll the provider and then resubmit the claim
When a provider's NPI is not recognized by the payer, the biller should work with the payer to complete credentialing or enrollment, then resubmit the claim once the provider is on file.
What is the significance of tracking the 'days in AR' (accounts receivable) metric in denial management?
Answer: It measures the average number of days it takes to collect payment after a claim is submitted
Days in AR measures the average time between claim submission and payment receipt, and a high number often signals denial or follow-up issues that are delaying revenue collection.
When a payer's remittance advice shows an OA-23 adjustment reason code, what does this mean?
Answer: The amount is not covered by Medicare; this is a Medicare Secondary Payer situation
OA-23 indicates that the payment was adjusted because Medicare is the secondary payer, meaning another insurance is primary and Medicare's payment reflects that coordination.
Which strategy is most effective when a payer continuously denies claims for the same incorrect reason?
Answer: Document the pattern, escalate to payer relations or a supervisor, and consider a formal complaint if unresolved
Systematic or recurring incorrect denials should be documented, escalated through payer relations channels, and reported to regulatory bodies if the payer fails to correct the issue.
What is a 'crossover claim' in the context of Medicare and Medicaid billing?
Answer: A claim automatically forwarded from Medicare to Medicaid for additional payment consideration for dual-eligible patients
A crossover claim is one that Medicare automatically forwards to Medicaid for patients who are dual-eligible, so Medicaid can pay any remaining cost-sharing amounts.