Failure to Address Denials or Incorrect Reimbursement From Third-Party Payors

ASC Revenue Leak Tip

Policies and procedures should be instituted to effectively address denials and initiate appeals. Follow these steps:

1. Determine denial trends by creating a log to track the cause(s) of claim denials:

• Registration error

• Form error

• Clearinghouse error

• Payor error

• No pre-authorization

• Coding error

• Non-ASC procedure

• No coverage at DOS

• Needs additional information

2. Understand each payor’s appeal process.

3. Create an effective appeals process that addresses all types of denials.

4. Initiate appeal promptly for non-payment or erroneous payment of claim. Try to resolve through online or telephone inquiries. If these attempts fail, file an immediate appeal by:

• verifying proper address for appeals;

• writing appeal letters and include information needed to support claims;

• taking appeals to highest level;

• requesting interest where applicable; and

• documenting all processes used with dates.

5. Review the final log at the end of the month. Ask payment poster to review the previous month’s log and prepare a report on the dispensation of the denials. If claims are in the appeals process, request update when the appeal is completed.

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