How can I Avoid Claim Denials?

Claims submitted incorrectly will ultimately be denied forcing providers to spend time and recourses on appeals. Furthermore, if a claim is presented with an incorrect billing code, the reimbursement rate differs from the contractual agreement. When this occurs, the ABA provider either has a balance due, or the funder pays less than that service’s reimbursement rate. This is another fitting example of why quickly reconciling claims is necessary to reduce claim denials.

Common but Preventable Errors

The primary objective for ABA providers is to provide high-quality and meaningful behavioral services to their clients and families while simultaneously and effortlessly managing the revenue cycles to keep their business operational. Increasing fluency with procedural codes and medical terminology specific to ABA is essential for successfully navigating insurance claims and the revenue cycle. Stall (2021) recommended two valuable resources for ABA providers to assist with understanding and processing and other billing management activities.

The American Medical Association (AMA) has been a trustworthy and dependable organization for over 50 years (AMA, n.d., accessed Jan 2022). The current set of CPT codes (Current Procedural Terminology) can be found at the link above, along with a wide variety of other guides and tools that can assist ABA agencies with the claims cycle and movement toward achieving a claim submission rate of 95% or higher (Stall, Brinkman & Padula, 2021).

Top 10 Mistakes Leading to Claim Denials

1. Medical Necessity Rationale: Clinical documentation fails to show the client meets criteria for medically necessary ABA services and/or targeted behaviors are not behavioral but fall under another service provider (i.e., educational, physical therapy)
2. DSM-5 criterion met: Clearly demonstrates the client’s behavioral, social, and communication deficits are directly linked to characteristics outlined in the diagnostic manual.
3. Missing Credentials: The provider conducting the services is not included on the claims form and/or the diagnosing physician is not included on the assessment or treatment plan.
4. Diagnostic Report: The diagnostic report does not meet funder guidelines stipulating a stage 2 provider assessed the client and provided the diagnosis of ASD.
5. Eligibility Issues: Failed to conduct an eligibility review prior to beginning services and ABA is not a covered benefit on a health plan.
6. Prior Authorization: Prior authorization (PA) was not provided by the payer before the service was rendered to the provider (“Top Claim Denials,” n.d.).
7. Authorization Number: Failed to include the authorization number on the claim prior to submission.
8. Required Documentation: Failed to attach required documentation (i.e., assessments, graphs, doctor prescription) prior to submission.
9. Deadlines: Failure to meet submission deadlines for claims, reconciliation claims, and/or appeals. CPT
10. Codes & Modifiers: Incorrect use of CPT codes, Modifiers, and patient diagnosis are correct. (Stall, Brinkman & Padula, 2021).

Now that you know the mistakes that lead to claim denials, focus on the steps to take to ensure claim success. Our Claim Submission Cheat Sheet is a step-by-step guide that aids you in ensuring your claims are being filed correctly for each client.  Download our Claim Submission Cheat Sheet to assist you in managing your claims processing.

References

Stall, D., Brinkman, M., & Padula, N. (2021). Billing 101: Claims Processing – Ensuring Efficient Management of Your Revenue Cycle. Presentation, webinar.