Stop the Increase in Medicare Denials

Have you been noticing an increase in denials from Medicare lately?  We have been getting an unprecedented amount of denials for “name and ID# do not match”.  We are getting these denials on claims for mental health providers who have been seeing and getting paid on claims for these same patients for months or even years.  Why now are these claims denying for name and ID do not match?  Good question.  It is not easy to find the answer.  We’ve called Medicare several times and were told that the name and ID do not match.  That’s all they would tell us – same thing the eob told us.  We would explain that we were paid for previous dates but it didn’t matter to the representative.  The name and ID did not match.

Finally we got to the bottom of this challenge!  We eventually talked to a helpful representative who gave us the answer.  It seems to be due to a change in their processing guidelines.  Any claim now submitted to Medicare must be entered exactly as the ID card shows.  If there is a middle initial, your claim must have a middle initial.  If there is a hyphenated name, the hyphen must be included. If there is a space, the space must be included.  If you have misspelled the name, the claim will be denied.  It is now extremely important to get a copy of the patient’s ID card so you can be sure you have it exactly as represented on the card.  In fact we have had claims denied that did match exactly.  Only after speaking to a representative and proving the claim matched the ID card would Medicare pay.

We have also found Medicare claims denied and the patient name on the denial completely different than the name we submitted.  When we called on this claim and the representative looked at it we were told that they could see that we submitted with the correct name and they weren’t sure what changed it in the system, but they would reprocess.  It seems to us that Medicare is making it harder than ever to get claims correctly processed.  Maybe it is a money saving technique on their part.  If your office is not following up on these denials and running regular aging reports you are losing lots of money.

Make sure your office is not missing out on payment for these claims.  Take care of the denials by whatever steps are necessary.  Run and work regular aging reports to avoid timely filing issues.  If you run a billing service, this is a great way to stand out above others.  Make sure you quickly remedy these issues.  Ask your providers for copies of each patient’s ID cards and keep them on file.  When you get any denials act on them immediately.  Don’t put them away for when you have time.  These problems need to be dealt with quickly.

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10 Responses to “Stop the Increase in Medicare Denials”

  1. Senthil Muthiah Says:

    Thank you for valuable information

  2. Shannon Kropp Says:

    “Maybe it is a money saving technique on their part” is a VERY good observation! I have suspected this for a long time. Not too long ago, I actually spoke with an insurance representative that told me it was his/her job to find reasons to deny a claim rather than to pay the claim. He/she later told me that the claims adjusters are paid a quarterly bonus based on denied claims. It seems unfair that the insurance companies have “rules” for us to follow and either they themselves do not follow the rules or they change the rules without any sort of notification to providers (or billing services). It is extremely frustrating.

    I agree that if you are not diligent about working the A/R things like this can slip through the cracks and can add up to A LOT of lost revenue. The worst part was that had the “original” error(s) been corrected immediately, the trickle-down effect of later dates of service denying for the same reason(s) would have been resolved immediately and payment would have been made.

    I used to work for a billing service that the owner said he did not have time to work any unpaid (zero) EOBs so he created an “issue folder” until someone “had time” to go through them. Finally, one of my colleagues and I got frustrated seeing the folder growing out of control (it was nearly 10 inches thick – SERIOUSLY!). She and I dove into the folder and worked it for two weeks straight until everything was taken care of. We found “simple” things like “applied toward deductible”, “coordination of benefits – patient liability”, “submit to primary carrier”, “no authorization”, “claims should go to X insurance”, etc. After all errors were fixed, one provider’s A/R dropped by $40,000!!! Of course, when the provider found out he/she called to see what happened…thankfully, I did not take that call, I can only imagine what was said.

    • solutionsmedicalbilling Says:

      You are hired! We have a hard time finding employees willing to do what you did. Many of the employees we have had in the past did not want to bother with unpaid claims. Those employees aren’t here any more. They don’t last. Congratulations to you for your attitude in getting all claims paid. It is rare!

      • Shannon Kropp Says:

        Thank you for the compliment. I absolutely LOVE what I do! It’s fun and challenging at the same time. There are days I want to pull my hair out, but that is usually only during month-end when people do not balance (I balance to the $0.01 and will hunt until I find it).

        I once “hounded” Blue Care Network for $60.55 for nearly two years. I know that I probably should have written it off and said “forget it”, but it was the principle of the denial that really “urked” me….BCN said the provider was not in network, however, I had a welcome letter from them that clearly showed the doctor was in network.

        One doctor dubbed me the “hound dog of medical billing”. I love it!

    • pmrnc Says:

      That’s absolutely NOT true. I’ve worked for several insurance companies in the claims department. Their claims processing systems are set to flag certain things. While it is true examiners receive administrative decision making powers according to their level of employment, they do NOT receive bonus’s or compensation based on claim denials. The systems used by carriers is too sophisticated for examiners to practice unfair claims practices. In addition they are penalized for complaints filed with the Dept of Insurane. A lot of people believe a lot of misinformation about insurance carriers. Many of them are nothing but rumors. The type of denial spoken about in this article is actually pretty reasonable, having the patient’s name and number matching EXACTLY is no different than making sure your provider’s NPI number matches the record EXACTLY to your IRS identifiers.

  3. Vijaya. Says:

    Thank you for this wonderful info I recently encounerted this problem on one of my Medicare patient ( mental Health problem)

  4. Binta Patel Says:

    Great article. useful information. As I am just starting my billing company appreciate the information on the article

  5. Nithin Johnson Says:

    We can get the correct Member name by checking it on the Medicare Online Provider Services and then fill the claim out with the same name as shown in the web site.

  6. Donyelle J. Says:

    Thank you sooo much because this has become a huge problem for my practice as well. Now we just have to get our edi system on the same page!


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