Q & A: Why is Medicare Denying Claims?

by 
February 23rd, 2015

Q: We have recently enrolled with Medicare and treat only a few patients. However, those claims are being denied. Can you help me to understand why this might be happening?

A: First, I would recommend you carefully review your Medicare Remittance Advice as that will identify the reason Medicare is denying your claims. Without looking at those myself, it would be difficult for me to say precisely why you are being denied.  

Secondly, I would also check to make sure you have the correct information regarding Medicare coverage for chiropractic. Section 30.5 of Chapter 15 of the Medicare Benefit Policy Manual identifies this for you (see page 20), as does your Local Coverage Determination (LCD) which can be obtained from your local Medicare carrier.  

And finally, from a claim form perspective, there are common errors that are easily recognizable and often the cause of Medicare denials. These things are:

1. Patient information: The name and information on the claim form must be the same as it appears on the Medicare Part B card.

2. Medicare has specific rules for properly reporting modifiers on claims. One reference to this is linked here.

3. If expecting payment, the diagnoses used must be those that are listed on the Medicare approved list for coverage and also must be listed in the correct order as defined by most Medicare carriers. For this information, please reference the website of your local Medicare carrier and view the LCD for chiropractic.