If there’s one constant in healthcare, it’s the fact that medical billing has always, and will always be a tedious and cumbersome task. Billing systems and software support being designed for the bulk of claim volumes (group health & Medicare/Medicaid) and complex claims with complicated submission requirements make the billing process almost entirely manual and inherently fraught with issues. Veterans Administration and TRICARE claims are becoming a bigger part of the mix, and the cost and risk continues to grow exponentially for providers.
VA claims require equal parts expertise, patience, and compassion. Knowing what it takes to meet the exact standards of the respective VA/DOD payer requires extensive background knowledge and expertise, and even if done correctly, providers will still face constant issues related to denials, underpayments, and an inventory of aged accounts. Simply put, with VA claims, if it’s not documented and coordinated properly, it didn’t happen per the prescribed ruleset for processing. This often leads to rejected and denied claims.
No matter how knowledgeable or precise your billing team is, claims will get rejected or denied. Although some use these terms interchangeably, they mean completely different things. Understanding these differences is essential to ensuring the reimbursement process for VA claims is handled appropriately.
What are Rejected Claims?
Claims that have been submitted to a clearinghouse but do not meet specific data requirements or the basic format required will be rejected. Typos, misspellings, terminated patient policy or incorrect coding are some of the reasons that a claim can be rejected. Rejected claims are not yet submitted to the payer, thus do not make it to the adjudication system. Since the claim hasn’t been submitted to the payer yet, it can be resubmitted once all errors are corrected. Be mindful, however, there is still a timeline as to when a claim needs to be filed, so delaying the resubmission of a claim can be costly.
What are Denied Claims?
Denied claims come directly from the payer. A denial occurs due to a payer determining they are not going to pay the claim. These denials can happen for several reasons – need for authorization, the claim was filed too late, the payer didn’t feel the service was medically necessary based on the documentation provided, and more.
Once a claim has been denied the remedy is a bit more complex. Denied claims go through an appeals process where a provider asks the payer to review their decision to not pay by providing additional information, including clinical details and more.
Now that we know the difference between a rejected claim and a denied claim, let’s begin the countdown, starting with number 10, of the top 10 reasons why VA hospital claims are rejected.
10. Invalid Type of Bill code: This rejection occurs when required diagnosis or procedural coding information on a claim is illogical, incorrect, or no longer in effect.
9. Missing Patient Account Number: A patient account number is a unique set of numbers assigned to an individual patient, for each unique episode of care. This unique identifier is a required field on every claim. If it doesn’t exist, the claim gets rejected.
8. Claim contains invalid or missing “Patient Reason” diagnosis code: This rejection occurs when there is a missing or incorrect diagnosis code, or“Patient Reason DX” in box 70. This field must provide the reason for the Veteran seeing the provider and at least one official code from the American Medical Association (AMA) database on the form.
7. Claim contains ICD9 Principal Dx code: ICD10 codes must be used for dates of service after 09/30/2015. ICD9 codes can no longer be used for the principal diagnosis code on a claim.
6. Claim contains missing or invalid Patient Status: A Patient Status is a field on a claim that describes the patient’s discharge status. If this field is blank, or includes an incorrect status code, the claim will be rejected.
5. Claim contains a missing/incomplete/invalid Billing Provider Address: This rejection occurs when there is an incorrect address, or missing address, for the provider location where the care took place.
4. Referring and Attending Physician NPI are equal: As of January 1, 2013, claims must include the NPI of the attending provider in the Attending Provider Name and Identifiers Fields on your claims. That NPI must not be your billing NPI or an organizational NPI; it must an individual provider NPI.
3. Missing Admission Type when Admission Date is present: If there is an Admission Date on a claim, this means the patient is an inpatient. Therefore, the Admission Type field must be present to address the reason for admitting the patient.
2. The outpatient claim has a missing “Admission Type” code: Admission Type code describes the primary reason for the urgency and priority of care the patient requires.
And the number one reason, according to the Department of Veterans Affairs, why a VA hospital claim is rejected…
1. Missing/incomplete/invalid Insured ID: This rejection occurs when this field, which requires a 17 alpha-numeric internal control (ICN) [format:10 digits + “V” + 6 digits] or 9 digit social security number (SSN) with no special characters, is missing or incomplete.
The simplicity of this top 10 list is misleading. These denial reasons can be considered minor issues to fix, however in terms of resolution timelines, they can add months or even years to the process. Having ‘clean claims’ upon initial submission is critical to getting paid quickly and accurately, especially for the VA/TRICARE! Most healthcare organizations find that it ultimately takes a substantial investment in numerous in-house SME’s to master the nuances of VA claims.
Specialization and bringing an economy of scale to this problem absolutely pays off for CBO leaders considering bringing in an expert. Having a business partner that knows and understands the VA’s goals, tendencies, and motives only makes more sense. At EnableComp, we are currently seeing a 41% decrease in time to collect with an average increase of 25% – 40% in VA collections in 98 days or less. Our proprietary technology, Enforcer360, is the most efficient provider-based comprehensive workflow engine in the marketplace.
As we continue to understand where the VA wants to go, we learn and understand their myriad of processes and procedures. Every additional claim makes our AI “smarter” and enhances our data-driven RPA leading to a real bottom-line impact for providers. With built-in reimbursement modeling, underpayment identification, and automated workflows, our software helps our team provide you the highest yield and best-in-class outcomes in less time. For assistance with VA billing to reduce your days to pay, increase your recovery yield, removal of the ‘headache/distraction’, internal staffing issues, and staying in compliance with your Veteran population, we are the team you can trust.