While denials are problems that no one wants to handle, they can still come up from time to time. Physical therapy denials, for example, happen more frequently than you may expect. These denials can siphon a significant amount of money from your practice, draining cash flow, and clinic resources.
The best way for you to deal with physical therapy denials is to make sure they never happen in the first place. Keeping this in mind, these are some of the ways you can make sure that physical therapy denials can be avoided or otherwise fixed.
Dealing With Billing Errors
Billing errors, like duplicate claims, often bring about private insurance claim denials instead of judgments regarding how appropriate the services are. To explain it in another manner, providers do not get paid for services that they provide solely due to not filing clean claims.
Process improvements are the way to go when handling billing errors, and getting new billing software integrated into your practice’s EMR can really make a difference. There’s a strong chance that the practices that get claim denials because of multiple claim submissions from one patient and on the same date of service are the practices that use spreadsheets instead of using software that makes tracking files easier.
Handling Eligibility Problems
Eligibility issues are another common cause for claim denials. This means that beneficiaries don’t have eligibility for insurance coverage during the time that the services are provided to them, which is usually because coverage hadn’t yet started for them or because coverage was already eliminated. There is the possibility that you could win appeals on claims that get denied due to errors. However, there’s little chance that payers would be fine paying money for patients who aren’t eligible for coverage.
Fortunately, the fix here is quite simple, and that is to verify the insurance eligibility of your patients before their first appointment, then continue verifying it regularly. This will guarantee that you always have confirmation, letting you know that your patients have a solid reputation with their insurance network and that all the services you provide are covered.
Lack of Medical Necessity
Medical necessity is a broad term, and each payer will have a different definition to provide to their beneficiaries. Since there are so many potential definitions, we will use the one provided by Medicare to serve as an example. For other payers, you will want to contact each one independently to go over your contract or clarify with them what is deemed to be a medical necessity. Medicare deems a service to be medically necessary if it falls into the following categories:
- It is a safe and effective service.
- The frequency and amount of time are proper based on standard practices for the treatment of the diagnosis.
- The service satisfies the medical needs that the patient has.
- The service requires the skills of the therapist.
This definition leaves a good deal of interpretation. But with that said, physical therapists must document all of their rationale explaining why certain services were provided to certain patients and why they thought those services were appropriate for the situation. All treatment decisions must be able to be defended, and that means proving that they are medically necessary, and the proof is up to you to provide.
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