Medical Coding Strategies to Prevent Payer Denials

 As a former emergency department physician from the U.K., this individual was well aware of claim denials and rejections, with payers frequently withholding or reducing payments. However, it was only when his personal insurance company, denied his medical claim for a vitamin D test that he decided to delve deeper into the issue.

He found it challenging to comprehend how Cigna could make such a decision when the physician reviewer had limited knowledge about his medical history. The individual had been experiencing severe pain in his hips and acetabulum, with his physician suspecting a vitamin D deficiency.

Following the payer’s instructions, he appealed the denial, but unfortunately, health insurance upheld its initial decision. It was only after seeking an independent external review that finally reversed the denial. The external reviewer concluded that the test was medically necessary, considering the severity of the bone pain and the risk of bone fracture without vitamin D supplementation.

Working with an investigative reporter, it was discovered that his claim was one of around 60,000 denials made by the same reviewer within two months. Interviews with two former physicians revealed that the company utilized an algorithm to identify discrepancies between diagnoses and tests or procedures, leading to batch denials without a thorough examination of medical records.

The situation deeply troubled the individual, as he emphasized that physicians dedicate themselves to delivering the best possible care to patients, making sound clinical decisions, only to face disheartening denials.

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