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By: David A. Blakeley, Esq.

Praxis Healthcare Solutions, Senior Attorney

Let’s face it. Those of us who call insurance payers on a daily basis quickly learn the scripts that the representatives are given to read to us. Before long, we feel that we could have both sides of the conversation all by ourselves. We know that, with a given denial in front of them, the insurance company representatives are going to say certain things and make certain recommendations.

Many times, these scripted conversations will in fact get us down the road toward account resolution, but it is in the exceptions where we can really make a difference in our AR inventory. We have to combat the tendency to simply re-enact these scripts on account after account. We should be looking for the exceptional accounts, the outliers. The most powerful tool we have to recognize those accounts is a healthy curiosity.

What we, as AR professionals, must always bear in mind is that there is always a reason why a claim is being denied. Yes, many times, that reason is perfectly obvious – the Care Management Department failed to provide notice of an inpatient admission, the claim has been pended for accident details, a claim is showing an excessive contractual adjustment. In each of these cases, the reason seems self-evident, but what we must not lose sight of is that in order for that denial to occur, there was a break down somewhere in the billing cycle. Where that breakdown occurred can make all the difference in overturning that denial. In short, it’s not enough to know what the denial is and submit an appeal; we must also know why there was a process failure that created that denial. Perhaps an example is in order.

I recently dealt with a situation where I noted that we had a cluster of claims that had been underpaid. I reviewed the appeals that the client sent to the payer on these different accounts and thought they were more than adequate. Indeed, the evidence submitted by our client was irrefutable; yet, the claims were coming back with the determination that they had been priced correctly. So, I called the payer with a simple question: If our client had submitted clear documentation that the agreed upon payment amount was X, and the insurer was paying Y, the why was there a discrepancy?

Of course, the first level account rep for the payer wanted to just send the claim back to reprocess. I could have followed the script and said “ok,” and followed up in a month. I would of course then have been told the claim was determined to have processed correctly. Instead, I asked the representative why the payer was not taking notice of the proof provided in the appeal. He didn’t know, but that question set me up to go through a chain of supervisors and managers until I found someone at the payer who also was curious about the answer to my question.

As it turned out, the DRG was assigned an incorrect weight in the payer’s system. The payer was sending the claim back through its pricing software, but the calculation was going to continue to be wrong, no matter how many times the claim went back through and no matter how much documentation was submitted. We were able to get the weight corrected and the claim reprocessed. It paid the expected allowed to the penny. It only took the curiosity of one provider advocate and one payer supervisor to solve the problem.

That is the power of Why. The Adjustment Reason Code is only the first step in understanding how to salvage a denied claim. We at Praxis always talk about identifying the Root Cause of the denial – where in the Revenue Cycle the failure occurred that caused the denial. But there is more to it. We also should seek to question why that failure occurred where it did. May your curiosity never fail.