Three Tips to Minimizing Anesthesiology Denials

Minimizing anesthesiology denials (as well as denials for every specialty) is a constant goal for every billing professional. The unfortunate reality is that denials are a part of everyday life, and only add more complexity to a regulatory and compliance-heavy industry. 

However, with proper workflows and processes in place, professionals can more quickly and efficiently resolve denials that directly impact cash flow and limit billing costs. 

We previously tackled radiology claim denials – you can check out a few tips on how to limit these denials by reading our blog post, “Three Tips to Minimizing Radiology Claim Denials.”

Let’s take a look at some of the common issues along with some best practices on minimizing anesthesiology denials for your practice.

        1. ‘Not Medically Necessary’ – Not Again!!

One of the most common denials we see in regards to anesthesiology is the ‘not medically necessary’ reason. These denials are fairly consistent between all major healthcare carriers, with the ‘MAC (monitored anesthesia care) denial’ being most commonly linked to these occurrences. 

A MAC denial is commonly driven by the assumption that a surgical procedure provided a higher level of anesthesiological care than the required level of care detailed for that service.

Additionally, a claim linked with this denial can be caused by a lack of information or diagnosis; if the diagnosis on the claim does not clearly support the service, the claim will be denied. Also, the frequency of the claim might also cause a denial – for example, two cases in the same day will require an appeal. 

Therefore, in order to ensure reimbursement, it’s critical to keep all necessary documentation regarding each service – such as:

• The pre-Anesthesia evaluation report.
• The Anesthesia record.
• The ABN (if required). 

These documents will help you prove medical necessity, increasing your chances of claims reprocessing and payment if initially denied.

       2. Turning Out-of-network Services into In-network Claims

It’s very common in medical facilities for out-of-network anesthesiologists to perform anesthesia on patients. The issue is that it is normally discovered after the procedure or service that the provider was outside of the patient’s network, leaving that individual with high out-of-pocket expenses they’re responsible for paying. This oftentimes leaves the bill unpaid, or collecting the bare minimum for the service. Costs and payment transparency are now covered for patients in the No Surprises Act, which went into effect January 1, 2022. As a result, regulations will be changing, so we will be monitoring how this impacts billing as events progress.

While not technically a denial since this is more about attempting to collect high out-of-network fees, this is still one of the major issues for anesthesiologists’ RCM efforts. There is a provision that varies from payer to payer – whether it’s RAPS provision, PARE logic, RAPL policy – that enables out-of-network anesthesiologists to have their medical claims processed at a members’ in-network level of benefits. 

In many cases, patients with a PPO plan will include out-of-network benefits; be sure to investigate this option for other plans as well. For patients with this provision, their financial responsibilities are lower, greatly improving the chances that they will meet their financial obligation so that the anesthesiologist can be made whole. 

        3. The Problem with Pre-authorization

A final tip for minimizing anesthesiology denials is realizing that pre-authorization is a common hurdle that you’ll need to deal with. Even though pre-authorization doesn’t really make sense for anesthesia billing, due to the fact that anesthesiologists are blind providers since the patients don’t select them specifically, surgeons will oftentimes require pre-auth. When that happens, commercial payers will deny claims because they don’t have a pre-auth#.

Unfortunately, there isn’t much that can be done to proactively handle these claims before they get denied, so it’s important to have a well-built accounts receivable team in order to deal with these denial trends. Additionally, having a good appeals process is critical for making sure these claims get reprocessed and paid as soon as possible. 

Want to learn more about minimizing anesthesiology denials for your practice? Get in touch with an AdvantEdge expert now, or stay up to date on company and industry trends by visiting our LinkedIn page.