Billing - Denials

A patient’s claim for a high-cost infusion therapy is denied due to "experimental or investigational treatment." What should be the first course of action when handling this denial?

• Submit the claim to the secondary insurance

• Appeal with peer-reviewed articles and medical necessity documentation supporting the treatment

• Resubmit the claim with a different procedure code

• Contact the patient to bill them directly

A claim for a heart valve replacement is denied because the payer indicates that the procedure should have been performed at a specific in-network facility. What would be the most appropriate next step?

• Request an exception based on the urgency of care

• Resubmit the claim to the original payer

• Appeal, stating that the out-of-network provider was the patient's choice

• Bill the patient for the out-of-network difference

A claim for a patient’s chemotherapy treatment is denied for “exceeding the allowable frequency” of treatments under the payer's guidelines. How should you respond to this denial?

• Submit an appeal with supporting documentation explaining why more frequent treatments are medically necessary

• Resubmit the claim after waiting for the allowable frequency period to pass

• Bill the patient for the additional sessions

• Adjust the frequency to fit within the guidelines

A claim for diagnostic imaging is denied due to "bundling of services." What should your next action be?

• Appeal the denial, stating the procedures are distinct and separate

• Resubmit the claim with the codes unbundled

• Write off the services as non-billable

• Contact the payer to request clarification on which code to use for bundling

A claim for an inpatient hospital stay was denied due to "incorrect level of care" being billed. What is the appropriate next step to address this issue?

• Resubmit the claim with outpatient codes

• Appeal the denial with medical records justifying the inpatient stay

• Adjust the bill to reflect outpatient services and send it to the patient

• Submit a corrected claim as outpatient services

A claim for a surgical procedure is denied due to “inconsistent documentation of medical necessity.” How would you resolve this denial?

• Resubmit the claim with a more appropriate diagnosis code

• Submit an appeal with detailed provider notes, diagnostic tests, and treatment plans

• Change the diagnosis and resubmit the claim

• Rebill the procedure as a lower-cost service

A claim for anesthesia services during a surgery is denied because the primary surgeon’s claim was not submitted. What is the best way to resolve this issue?

• Appeal the denial and explain that the anesthesia was medically necessary regardless of the surgery

• Hold the claim until the surgeon submits their claim, then resubmit

• Submit the anesthesia claim as an independent service

• Contact the surgeon’s office to ensure their claim is submitted, then resubmit your claim

A claim for durable medical equipment (DME) is denied because the patient's insurance states that "proper documentation of continued need" was not provided. What steps should you take to correct this denial?

• Resubmit the claim with an updated prescription for the DME

• Appeal with the patient's medical records showing the necessity of continued use

• Contact the patient to request they cover the cost

• Submit a new claim for the same DME with a different code

A claim is denied for "coordination of benefits" because the patient has dual insurance coverage and primary payer information was missing. What should you do first?

• Bill the secondary insurance directly

• Obtain the primary insurance details from the patient and resubmit the claim

• Appeal the denial with the payer

• Write off the claim as uncollectible

A claim for outpatient physical therapy was denied because the payer stated that a referral was required, but none was submitted. What is the best way to resolve this issue?

• Obtain a retroactive referral from the referring physician and appeal the denial

• Appeal the denial without submitting a referral, as it is a common service

• Resubmit the claim and include the referring physician's information

• Bill the patient for the services directly