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Denials - Incorrectly Identified as a Duplicate DenialDifficulty: Moderately Simple // Patient Financial Services
Why run this play?
This play provides steps to overturn two highly recoverable types of denials: 1. Claims that were wrongly denied as a “duplicate claim submission” on first pass adjudication. 2. Claims that were incorrectly denied for “duplicate denial” where the original denial was not for a cross-over adjudication or where the Billing/Claims Team filed a claim with the incorrect bill type. Each of these situations are highly recoverable, the client can immediately see actionable claims that were denied incorrectly and take action to get the denial overturned.
Background
Payers often use a common stall tactic where they deny claims for duplicate denial when in fact the claim is a first pass denial. Incorrect identification also happens when the denied claim (with a bill code type of 1 or 2 in position 3) is not the first pass denial. That indicates an issue with the billing department incorrectly entering the bill/claim type number. Often, the billing process/claims team re-submits a claim when they are assisting the denials team in the appeal process. A process fracture occurs when the corrected claim is filed with a bill code type that is incorrectly stated as an original claim.
Take Action
Using your 835 remits, we recommend creating the following flag:
Where denial type = "Duplicate Claim" AND type of bill <> '%%1' OR '%%2' AND first remit is true then set = "first pass misclassification"
Where denial type = "duplicate claim" AND type of bill <> '%%1' OR '%%2' AND first remit is false then set = "non first pass misclassification"
If a First pass Misclassification:
Do not refer this account to the Denials Prevention and Recovery Team.
Instead, have the insurance Account Rep validate receipt of the claim via its claim scrubber/clearinghouse, then call the payer with a received claim number (this varies by claim scrubber but a number or key is assigned upon successful receipt of the claim by the payer).
Inform the payer that they have denied a claim as a duplicate when only one claim was submitted.
Validate that there are no other issues that prevent the adjudication of the claim from occurring.
If applicable, move the account into a promise to pay disposition.
Be sure that the Insurance Account Rep does not re-submit a second claim unless absolutely necessary because that opens the door for an additional duplicate denial stall tactic by the payer.
- If it is a non first pass misclassification:
- It appears the claims specialist submitted the claim with the incorrect claim type number.
- Determine if a claim needs to be sent to the payer with an appeal letter, or if it requires a simple phone call.
- If the claim needs to be included with the appeal letter, then ensure that the claim type <>1 or 2.
Want to see how to run this play in VisiQuate?
Request a demoAdditional plays you might find useful
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