This is part one of a three-part series dedicated to navigating the unfortunate reality that air ambulance claims are routinely underpaid or denied. Knowing what steps to take to prevent your claim from reaching the IDR process can save time, resources, and potential delays in payment.
To avoid the need for arbitration, providers can take proactive steps to improve their claim submission process, streamline communication with payors, and enhance documentation practices. Here’s how air ambulance providers can prevent claims from escalating to the IDR process:
1. Accurate and Complete Documentation
One of the most common reasons for claim disputes is insufficient or unclear documentation. Ensuring comprehensive and accurate documentation from the start will help minimize the risk of denial or underpayment.
- Medical Necessity Justification: Clearly document why air transport was required, including details about the patient’s condition, the urgency of the situation, and why ground transport wasn’t appropriate (e.g., time-sensitive trauma, inaccessible location, distance to appropriate care).
- Patient Information: Verify all patient data (such as demographics, insurance details, and contact information) and ensure that medical records, signatures, and authorizations are complete.
- Detailed Clinical Records: Include all relevant clinical interventions performed during transport, the patient’s response to treatment, and any complications that occurred.
2. Know and Follow Payor Policies
Each payor has its own guidelines for reimbursement, and familiarity with those policies is crucial to prevent claim disputes. Understanding how different payors handle air ambulance claims allows providers to adjust their submissions accordingly.
- Payor-Specific Requirements: Review payor specific medical policies to ensure compliance with their coverage criteria. Some payors may require certain documentation for reimbursement. Following these requirements can prevent denials based on technicalities.
3. Establish Clear Communication with Payors
Effective communication with payors before and during the claims process can help prevent disputes. Providers should actively engage with payors to clarify coverage questions and resolve potential issues early on.
- Early Resolution of Issues: If a payor indicates that a claim is headed for underpayment or denial, initiate discussions immediately. Addressing concerns early can help avoid the need for IDR.
- Document Communication: Keep detailed records of all interactions with payors, including phone calls, emails, and correspondence. This documentation can be useful if disputes arise and helps show the efforts made to resolve issues without arbitration.
4. Optimize Billing and Coding Practices
Proper billing and coding practices can prevent disputes over reimbursement and reduce the chances of claims being sent to IDR.
- Correct Use of HCPCS and ICD-10 Codes: Ensure the correct use of air ambulance HCPCS codes and include detailed information about mileage, level of care, and services rendered during the transport. Ensure ICD-10 codes are applied to the claim to accurately describe the condition of the patient at the time of transport.
- Use of Origin and Destination Modifiers: Accurately assign origin and destination modifiers to indicate where the patient was picked up and transported. Incorrect modifiers can trigger denials.
- Avoid Common Coding Errors: Review claims for potential coding mistakes, including incorrect modifiers, duplicate billing, or billing for services not rendered. Routine audits can help catch these errors before submission.
5. Train Staff on Claims Best Practices
Staff involved in the claims process should be well-trained in both the clinical and administrative requirements for air ambulance billing.
- Ongoing Education: Keep billing and coding staff up to date with the latest changes in payor policies, coding guidelines, and industry regulations. Ongoing education will help them stay compliant with requirements and avoid costly mistakes.
- Audit and Review: Regularly audit submitted claims to identify any patterns of errors or denials. These audits can help pinpoint where improvements in documentation or coding practices may be needed.
6. Appeal Denials Early
If a claim is denied or underpaid, don’t wait for the dispute to escalate to IDR. Promptly initiate an internal appeal with the payor.
- Appeal with Strong Justification: Prepare a detailed appeal with supporting documentation, including any medical necessity justifications, clinical records, and relevant industry standards or market data that support the charges.
- Follow Payor’s Appeals Process: Adhere to the payor’s specific appeals process, including deadlines and submission requirements. A well-documented appeal submitted within the required timeframe can often lead to a resolution without the need for IDR.
7. Preemptively Identify High-Risk Claims
Some air ambulance claims are more likely to face scrutiny, particularly high-dollar transports or those involving out-of-network services. By identifying these high-risk claims early, providers can take additional steps to ensure a smooth submission process.
- Flag High-Risk Claims: Set up processes to flag high-risk claims that may face denials or disputes. These might include out-of-network claims, transports with higher-than-average charges, or cases where medical necessity may be questioned.
- Additional Documentation for High-Risk Claims: Ensure that high-risk claims have the most detailed and comprehensive documentation possible before submission. Providing clear clinical justification upfront can help avoid disputes.
Preventing air ambulance claims from reaching the IDR process involves a proactive approach focused on thorough documentation, understanding payor policies, and optimizing the claims process. By enhancing communication with payors, training staff, and leveraging technology, air ambulance providers can minimize denials and avoid the need for arbitration, ultimately ensuring faster and more efficient payment.
