4 Reasons for Physical Therapy Claim Denials and Solutions
Denied claims are the type of claims that were received and processed by the insurance payer and a negative determination was made. It is no wonder that in Physical Therapy there are a greater number of denied claims compared to any other specialty.
Here are 4 reasons for claim denials in Physical Therapy and ways to rectify them:
Billing Errors in Physical Therapy Claims
A significant percentage of claims are denied due to simple errors such as missing information or duplicate claims. Most private insurance claims are denied due to billing errors rather than the appropriateness of the services offered. Service providers are not being paid for their services simply because they are not submitting a clean claim or submitting the same claim twice.
Solution:
Improving the clean claim submission rate requires clean underlying processes. Ensure that your billing process is streamlined, you use a PT focused billing system, and there is a tight integration between your billing system and EMR. That will help you improve the clean claim submission rate if you continue to use internal resources for billing. One of the better strategies would be to outsource the medical billing process to a credible offshore medical billing company like Medical Billing Wholesalers. When you outsource/offshore your billing process, you immediately get access to streamlined processes, eliminate your A/R backlog, and improve reimbursements.
Eligibility Issues in Physical Therapy Billing
A significant reason for claim denials can be eligibility issues. This means that the procedure was not covered by the insurance when you offered it, or the procedure cannot be included in the insurance scheme. It is more difficult to get the payer to pay-off claims due to eligibility issues compared to denials due to errors.
Solution:
Maintain regular checks on the patient’s insurance eligibility before the first appointment in the clinic. By doing this you can ensure if the patient is eligible for the services and the payments for the services sought will be covered by the insurance company. It is a good practice to check eligibility for each subsequent visit. This might also help you determine if a particular payer requires prior authorization for the services.
Misuse of modifier 59
A modifier 59 should never be used to claim for a procedure that would otherwise be bundled with another procedure. Inappropriate usage is considered as abuse and results in claim denials.
Solution
A modifier 59 should be used only when there is a need to indicate that a physician performed a unique procedure that is independent of the other procedures on the same day. Simply put, modifier 59 should be used to indicate a procedure that would normally be bundled with other services. This can be done on the same/different patient, on the same/different location. Also, If another modifier is deemed more suitable -- it must be used instead of modifier 59. It is always wise to contact the payer when you don’t know what to use.
Lack of Medical Necessity – Key Reason for PT Claim Denials
Considering a large number of insurance payers, it is not surprising to know that medical necessity is a reason for claim denials. A procedure is considered medically unnecessary when the Therapist does not have a defensible document supporting his/her decision to perform a procedure.
Solution:
To prevent claims denial due to lack of medical necessity, ensure the following details:
Confirm that the condition requires a therapist’s skill.
The procedure must be safe and effective
Fix a duration and frequency based on standard practices for the diagnosis or treatment
Assure patient satisfaction by meeting the medical needs of the patient
Physical Therapy Billing demands focus and expertise. Beyond all that it requires an eye for detail. Preventing the four major reasons for claim denial can help you save a lot of your time and energy.
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