A 2011 report by the U.S. Government Accountability Office (GAO) found that aggregate rates of coverage denials in the states reviewed, including denials of pre-authorizations and claims, ranged from 11% to 24%.1 Each denial has significant downstream impact on a practice: the average cost to rework a single claim is $252 and resource-intensive appeals can take months with no guarantee of success with many practices ending up with write-offs in the range of 1% to 5%.3 Regardless of number, denials can be detrimental to the health and sustainability of a practice.
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- U.S. Government Accountability Office (GAO): “Private Health Insurance: http://www.gao.gov/products/GAO-11-268
- MGMA Connection, “How to avoid ‘unclean’ claims,” by Amber Taufen, MA, March 28, 2014. http://www.mgma.com/practice-resources/mgma-connection-plus/online-only/2014/march/how-to-avoid-unclean-claims
- Becker’s Hospital CFO Report, “4 ways healthcare organizations can reduce claim denials,” by Kelly Gooch, July 26, 2016.http://www.beckershospitalreview.com/finance/4-ways-healthcare-organizations-can-reduce-claim-denials.html
This information is derived from a variety of public sources and is provided for informational purposes only. Payment varies by geographic location, coverage and payer. It does not constitute reimbursement or legal advice. It is not intended to increase or maximize reimbursement by any payer. Avanos does not warrant or guarantee that the use of this information will result in coverage or payment. Avanos encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered.
Avanos recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage, and reimbursement matters. Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements.