Question

I am having an extremely difficult time getting reimbursed by [insurance carrier]. They keep denying everything as maintenance. Why?

Answer

There are several reasons why a carrier denies a claim as maintenance.

It is up to the provider to prove medical necessity by appropriately documenting the patient encounter in accordance with established guidelines. The important thing is to include the complaint, objective findings, and then create a plan with goals. It is important to demonstrate that there is progress or improvement.

Some other possibilities are:

• The initial date in Box 14 is too old
• The frequency of visits are too regular (i.e. monthly visits)
• The documentation does not show a plan, end point, or progress.
• Diagnoses are the same as those that have been used for the same patient(s) for an excessive amount of time.