Emergency Medicine & Anesthesia Denials: Analyzing and Taking Action

At large emergency medicine providers, revenue cycle teams are constantly submitting claims for a large mix of services across a range of payers. When claims get denied, it becomes quite time consuming to sort through the denials to understand why specific claims have been denied and how you can take corrective courses of action.

This is a challenge that arises time and time again for anesthesia denials. Anesthesia denials could be caused by a range of reasons. To name a few:

1. Coding errors: Anesthesia claims are particularly complex, they require a procedure code, concurrency modifier, physical status, and time units, this increases room for error on the claim itself, increasing the probability of a denial.
2. Medical necessity: The anesthesia could be considered “not medically necessary,” due to the payer assuming that the patient was provided a higher level of anesthesiological care than what was required for their service. 
3. Missing documentation: It could also be considered “not medically necessary” due to a result of a lack of information — if the payer does not see a diagnosis on the claim that clearly requires the anesthesia provided, it will be denied. This is typically a case of missing documentation, so it’s crucial to remember to submit any and all related documentation, including the pre-anesthesia evaluation report, the anesthesia record, and the ABN.
4. Out-of-network services: An out of network anesthesiologist provided the care. While a patient may be seeing a provider that is considered in-network, the anesthesiologist may be out of network for their insurance. This results in high out of network fees, and due to varying regulations from payer to payers (such as RAPS provisions, PARE logic, or RAPL policies), out of network anesthesiologists can have medical claims processes under patient’s in network benefits.

If your revenue cycle team receives a number of anesthesia related denials, it can be incredibly manual and time consuming to go through the list of denials, understand at a claim level why each denial occurred, and then take the necessary steps to contest the denial. 

That’s where a tool like Adonis Intelligence can come in handy.

Technology to Analyze, Organize, and Action Denials

Adonis Intelligence helps revenue cycle teams in emergency services respond to the large sum of anesthesia related denials that they see every week. Intelligence can organize and prioritize denials automatically, so teams know the steps they need to take to address each denial.

For example, instead of the tedious and time consuming process of manually combing through denials and figuring out how to contest each one, Adonis Intelligence:

1. Analyzes claims to understand the reason behind each denial
2. Sorts these denials either by reason, payer, or action required (ie. gather additional documentation, correct the coding error, etc)
3. Assign these worklists to each member of your team, so everyone has a specific action-oriented worklist to prioritize

By organizing and assigning worklists by payer or action required, teams save time by being able to focus their efforts in one specific area, rather than jumping between different tools, technologies, or payer requirements. 

This improves denial response time and increases speed to cash — driving bottom line revenue for the emergency department.