Minimizing anesthesiology denials (as well as denials for every specialty) is a constant goal for every billing professional. Unfortunately, denials are routine in healthcare billing, further complicating regulatory and compliance matters.
However, with proper workflows and processes, billing professionals can more quickly and efficiently resolve denials that directly impact cash flow and limit billing costs.
Let’s look at some of the common issues and some best practices for minimizing anesthesiology denials:
1. ‘Not medically necessary’
One of the most common denials regarding anesthesiology is the ‘not medically necessary’ reason. These denials are consistent among all major healthcare carriers, with the ‘MAC (monitored anesthesia care) denial’ most linked to these occurrences.
MAC denials can occur when it’s assumed that a surgical procedure required a higher level of anesthesiological care than what was specified for the service.
Additionally, a lack of information or diagnosis can cause a claim linked with this denial. If the diagnosis on the claim does not support the service, the claim will be denied. The frequency of the claim might also cause a denial – for example, two cases on the same day will require an appeal.
Therefore, to ensure reimbursement, it’s critical to keep all necessary documentation regarding each service – such as:
- The pre-anesthesia evaluation report
- The anesthesia record.
- The Advance Beneficiary Notice – ABN (if required)
These documents will help you prove medical necessity, increasing your chances of claims reprocessing and payment if initially denied.
2. Turning out-of-network services into in-network claims
It’s prevalent in medical facilities for out-of-network anesthesiologists to perform anesthesia on patients. The issue is that it is commonly discovered after the procedure or service that the provider was outside the patient’s network, leaving that individual with high out-of-pocket expenses they’re responsible for paying. This often leaves the bill unpaid or collecting the bare minimum for the service.
Although not technically a denial, attempting to collect high out-of-network fees remains a significant issue in anesthesiologists’ RCM efforts. A provision that varies from payer to payer – whether it’s RAPS provision, PARE logic, or RAPL policy – enables out-of-network anesthesiologists to have their medical claims processed at a members’ in-network level of benefits.
In many cases, patients with a PPO plan will include out-of-network benefits; be sure to investigate this option for other plans as well. Patients with this provision have lower financial responsibilities, significantly improving the chances that they will meet their financial obligation.
3. The problem with prior authorization
A final tip for minimizing anesthesiology denials is realizing that prior authorization is a common hurdle for billing experts.
According to the American Medical Association (AMA), prior authorization is overused, and existing processes present significant administrative and clinical concerns.
Despite pre-authorization not always aligning with anesthesia billing – given that patients don’t specifically select anesthesiologists – surgeons often require it, leading to challenges. When that happens, commercial payers will deny claims because they don’t have a pre-auth.
Unfortunately, handling these claims proactively before denial isn’t feasible. Therefore, having a well-built accounts receivable team is vital to deal with these denial trends. Additionally, ensuring a robust appeals process becomes crucial to promptly reprocess and secure payment for these claims.
Outsourcing your prior authorization process is also a good option. Outsourcing this process to a trustful partner can help you:
- Reduce denials
- Save time and money
- Minimize data errors
- Improve patient care
Read more about the benefits of outsourcing this billing process in our blog 4 reasons to outsource your prior authorizations process.
At Health Prime, we understand the importance of minimizing anesthesiology denials for your practice to optimize your workflows, increase revenue, and ensure you get paid for your work.
If you want more information about reducing your denial rate, feel free to email us any questions at [email protected]. Let’s discuss how Health Prime can help you get your practice back in its prime.
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