Q&A: Resubmitting denied claims

November 4, 2019
Medicare Web

Q: How should we handle denied claims when the payer refuses payment under the billed status? Do we need to document that the status was changed only because the payer did not agree to any other options?

A: On occasion, a payer may refuse to pay a claim under the billed status but agree to pay it under a different status, such as refusing a claim for medical services as an inpatient when the payer believes the services could have been performed as an outpatient. Another twist to this is when the payer refuses to pay a claim based on one or more codes but is willing to pay it under certain other codes. Both of these scenarios require investigation, similar to what was described earlier. However, in these situations, the organization is not being denied payment, just denied the payment under the terms it claimed.

In both cases, if the provider does not agree with the options offered, and exhausts all appeal options, the provider should proceed to resubmit the claim with the revisions required by the payer. However, the provider should clearly document in the billing and coding notes that the changes (what they were originally and what was changed per payer demand) were required by the payer. Additionally, the organization may need to adjust a patient’s deductible or copay if the status changed, but this will usually be handled by PFS. While this challenge is rare and frustrating, I am reminded by what my colleague, Charlotte Barret, AVP, from Health Information Integrity, said: “He who has the gold makes the rules!” The payer has the gold.

For more information, see JustCoding's Practical Guide to Coding Management, Second Edition.