In our previous post on how to avoid initial denials of reimbursement claims for viscosupplementation, we discuss how the demand for osteoarthritis therapy viscosupplementation has been rising and will continue to rise nearly 10% every year for the next five years.
This trend, driven by an aging population, may well become the bread and butter for orthopedic practices and departments. And yet, a constant nuisance remains with even the most popular procedures: denials.
This post covers how to adeptly handle a viscosupplementation denial once it’s already been issued.
Investing the time pays off.
Across all healthcare, 50% to 60% of all medical denials are ignored by back office staff. Given that an appeal is successful in 40% of cases, providers stand to recoup significant revenue when they dedicate staff, time, and effort to appeals. Go through these steps carefully to have the best chance of winning an appeal when viscosupplementation is initially denied.
Comprehensive Review And Correction Of A Viscosupplementation Claim After Denial
With the denial on your desk, act fast to avoid any deadlines. Take the following steps to work your appeal.
Review the payer’s explanation of benefits (EOB) – If the viscosupplementation is not within these benefits, the provider is responsible for the treatment.
Review identification numbers, patient names, missing signatures. Simple errors lie behind many viscosupplementation claim denials.
Review codes and their modifiers, another area where mistakes lead to denials.
Submit the corrected claim.
If everything on the claim form is correct, the claim may have lacked supporting documentation. To make sure you get the payer exactly what they want, call and ask for details about the information needed. You can request a reconsideration to have the claim re-reviewed by a claim specialist.
Make sure to include these documents when you seek reconsideration:
- Patient’s medical history
- Any other therapies attempted
- Therapies that were contraindicated
- Medical reasons behind patient’s viscosupplementation diagnosis
- Medical risks to the patient that could result from foregoing or delaying therapy.
- With this resubmission, send a letter specifying how the requirements have been met.
Remedy After A Second Denial
If the patient’s payer denies the claim after you’ve corrected or added documents to a claim, you can still file a grievance. Do so as soon as possible to avoid deadlines. Once you’ve filed your grievance, know your dates, so you can act if a deadline is coming up. You may also want to include the patient in the appeal process to put pressure on the payer.
Artificial Intelligence And Automation Help You Win More Appeals
The popularity of viscosupplementation is on the rise, and it’s not only a rising senior population driving it. More patients today prefer minimally invasive procedures over surgical ones, e.g. knee injection over knee surgery. In addition, seniors are determined to stay active into their 70s and 80s. They’re hearing from their friends that viscosupplementation can get them there.
In an era where legislation keeps favoring payers, providers can use technology to help them stay on top of denials and denial appeal deadlines.
Adding AI-powered revenue cycle management simplifies minimally invasive orthopedic procedures from the point of insurance verification and patient pay estimation through claims submissions and denials management. Orthopedics departments and providers can get and keep more of their revenue. Our clients have seen an average 40% reduction in denial rates and 64% in denial & aging A/R write-offs.
Schedule a demo to see how our solution helps move your denial appeals along and frees your staff to focus on patient interactions and knowledge work.