Understanding Claims Denials in Endovascular and Interventional OBLs and ASCs

In the healthcare industry, claims denials are a natural element of revenue cycle management (RCM) and can be a significant hurdle for endovascular and interventional office-based labs (OBLs) and ambulatory surgery centers (ASCs). These important healthcare facilities play a critical role in providing image-guided, minimally invasive procedures for patients with arterial and venous diseases, cardiac conditions, cancer, chronic pain, and other specialized needs.

However, claims denials are a common issue in these settings, leading to delayed reimbursements and increased administrative workload. Understanding the common reasons for claim denials, knowing how to appeal them effectively, and implementing strategies to minimize these issues can significantly improve the financial health of these practices.

Common Reasons for Claims Denials

1. Incorrect or Incomplete Documentation One of the leading causes of claims denials is improper or insufficient documentation. This includes missing or incorrect patient information, incomplete procedure notes, or lack of supporting evidence for medical necessity. In endovascular and interventional procedures, where precision is critical, proper documentation ensures that the services rendered are justified and clearly detailed.

Example: If a physician performs an interventional procedure such as an angioplasty and the operative report fails to include details on the condition of the vessel or why the procedure was medically necessary, the payer may deny the claim.

1. Failure to Obtain Prior Authorization Certain procedures, especially those in interventional radiology or endovascular therapy, may require prior authorization from the insurance provider before the procedure is performed. Failure to obtain this approval beforehand often results in claim denials. This is a common issue in OBLs and ASCs, where high-cost, specialized procedures may be overlooked in terms of authorization requirements.

Example: A complex stent placement procedure may require prior authorization for coverage, and failure to acquire this authorization may lead to a denial by the payer.

1. CPT/ICD Coding Errors Inaccurate coding or the use of outdated codes can trigger claim denials. It is essential for medical coders to accurately assign the correct Current Procedural Terminology (CPT) codes for the procedures performed and the correct International Classification of Diseases (ICD) codes for the patient’s diagnosis. An incorrect code, such as using a non-specific diagnosis code, could lead to the claim being rejected.

Example: An incorrect CPT code for an angioplasty procedure could lead to a denial if the payer is unable to match the service to a covered code in their reimbursement policies.

1. Unmet Medical Necessity Criteria Insurance companies require that procedures be medically necessary for coverage. If the documentation or coding does not support the necessity of the procedure, the insurance provider may deny the claim. This is especially important in interventional radiology and endovascular procedures where the line between necessary treatment and elective treatment can sometimes be blurred.

Example: If a claim for a stent placement in a non-emergent patient is submitted without sufficient evidence of medical necessity—such as imaging studies or physician notes indicating symptoms—the claim may be denied for lack of justification.

1. Provider/Facility Eligibility Issues If a provider or facility is not enrolled in the insurance plan or if there is a lapse in the provider’s credentialing, claims can be denied. This is often an administrative issue that can be easily avoided by ensuring that the practice is properly enrolled in all relevant insurance networks and that credentialing is up-to-date.
2. Timely Filing Limitations Payers impose strict timelines for submitting claims. If the claim is submitted after the deadline set by the payer, it will likely be denied. This is a common issue for outpatient facilities like ASCs and OBLs, where claim submissions may be delayed due to administrative backlogs or communication issues between departments.

How to Appeal Denied Claims

1. Review the Denial Notice The first step in appealing a denied claim is to thoroughly review the payer’s denial notice. This notice will explain the reason for denial and often includes a code that corresponds to the specific issue. Understanding the root cause is crucial to crafting an effective appeal.
2. Gather Supporting Documentation Once the reason for denial is identified, gather all relevant documentation to support the claim. This may include:
   • Patient charts and procedure notes
   • Imaging results
   • Preoperative and postoperative reports
   • Prior authorization records (if applicable)
   • Letters of medical necessity from the physician
3. Correct Errors in Documentation or Coding If the denial was due to incomplete or incorrect documentation or coding, correct these errors and provide the updated documentation in the appeal. For example, if a code was assigned incorrectly, provide a detailed explanation of the proper code and its relevance to the procedure.
4. Submit the Appeal Within the Allowed Timeframe Each payer has specific deadlines for submitting an appeal. Ensure that the appeal is filed within the timeframe outlined in the denial notice. A timely appeal improves the likelihood of successful resolution.
5. Follow Up After submitting the appeal, follow up with the payer regularly to ensure that it is being processed. Keep a detailed record of all communication with the payer.
6. Seek Assistance from a Billing Expert If appeals are repeatedly unsuccessful or the denial is complex, consider consulting with a healthcare billing expert or coding specialist who can assist in resolving the issue.

Best Ways to Minimize Claims Denials

1. Enhance Documentation Practices Ensure that all documentation is thorough, clear, and accurate. Develop a checklist for physicians and staff to follow when documenting procedures. This checklist should include key information, such as patient history, indications for the procedure, the type of procedure performed, and post-procedure outcomes.
2. Implement a Robust Prior Authorization Process Develop a process for ensuring that prior authorizations are obtained for all procedures requiring them. This may involve designating a staff member to handle prior authorizations, utilizing electronic systems for tracking authorization requests, and ensuring that all authorizations are obtained before procedures are performed.
3. Regularly Update Coding and Billing Knowledge Given the complexity and constant updates in CPT and ICD codes, it is crucial for billing and coding staff to remain educated on the latest codes and guidelines. Regular training, access to coding resources, and participation in relevant workshops can help minimize coding errors.
4. Verify Insurance Eligibility Always verify the patient’s insurance coverage before performing any procedures. Confirm that the facility and providers are in-network, and check for any coverage exclusions or special requirements.
5. Monitor Timely Filing Requirements Stay on top of each payer’s filing deadlines to avoid missing the submission window. Using an automated billing system that tracks submission dates can help mitigate this issue.
6. Leverage Technology for Claim Tracking Implementing a claim tracking system that allows staff to monitor the status of claims and track denials can be a proactive approach to addressing potential issues early. Many electronic health record (EHR) systems have integrated tools for managing claims and billing processes.

Conclusion

Claims denials are a common challenge faced by endovascular and interventional OBLs and ASCs, but they do not have to be an insurmountable obstacle. By understanding the root causes of denials, actively appealing claims when necessary, and implementing best practices for documentation, coding, and authorization, these facilities can reduce the occurrence of denials and improve their revenue cycle efficiency. Being proactive in addressing these issues can lead to smoother operations, faster reimbursements, and a healthier financial bottom line.