All practitioners, including physicians, occasionally experience claim denials. Reversing these denials depends on how diligent you are, and what process you and your practice implement to fight for the legitimate reimbursement dollars you have earned. As the financial productivity to the practice for all practitioners becomes increasingly scrutinized, you owe it to yourself to make sure that denied claims for medically necessary services are challenged.
Don't leave it to chance, and don't assume that individuals in the billing office are following up claim denials. Make sure that your practice fights as hard to reverse your claim denials as they do for your supervising physician.
Determine the exact reason for the denial
Don't guess or assume that you know the reason for the denial. Carefully review the explanation of benefits (EOB) to find the specific reason or the 2-digit code that appears on many EOBs explaining the denial. Did you perform a service not covered if delivered by any practitioner?
Is the denial due to coverage restrictions in the patient's insurance policy/contract?
Was a mistake made in filling out the claim form (e.g. incomplete or missing information)?
Should the claim have been submitted using the supervising physician's or medical group's name and provider number instead of the PA's?
Is the denial due solely to the fact that the service was provided by a PA?
If the denial was due to the fact that a PA provided care:
Before calling the payer, contact your chapter's reimbursement coordinator to see if other PAs have had problems with this particular payer. The problem may be with a new claims person unfamiliar with the PAs when in fact the company has a history of covering PAs. If the chapter's reimbursement coordinator has dealt with the payer before, there may be a specific contact person with whom you can speak to prevent having to "reinvent the wheel" with someone less familiar with PAs.
The AAPA is setting up a "Payer Data Bank" in an attempt to keep an ongoing record of the specific payment policies of public (Medicaid, workers' compensation) and private payers. You or your state reimbursement coordinator should let the AAPA know when problems occur so the payer can be added to our database. This will also help us determine which payers to personally contact and visit in our ongoing effort to educate payers.
When you contact the national office, we can pass along information such as the names of individuals with whom we have worked or spoken that may be useful in helping resolve your problem.
Contacting the payer
Many payers don't have an official policy regarding coverage of medical services provided by PAs. Contacting a payer about a specific claim may send up an unwanted red flag for you and your practice. If the payer decides that it will not or does not cover PAs and your practice has been billing and receiving reimbursement for your services (even if somewhat sporadically), the payer may decide to look into its payment history to the practice. If there has been inappropriate billing, they may try to recover funds.
Consider asking questions of the carrier as a general information inquiry, without giving much data about yourself or the practice. The AAPA staff (Michael Powe or Fauzea Hussain) is willing to contact the payer on your behalf to gather additional information.