If your practice is having Transcranial Magnetic Stimulation (TMS) claims denied, you are not alone. Medical billing claims can be tricky to get right. But once you are faced with a TMS denial, what should you do?
Your instinct might be to appeal right away, but that should be far from the first step. Here are a few strategies to consider.
1. Look for Corrections Before Appealing
Insurance companies will likely scrutinize TMS claims particularly closely. Many claims are denied for small errors: an incorrect diagnostic code for example, or even diagnostic codes in the wrong order. Mistakes happen: there are no perfect people!
Your first step should be to send the claim back to the coder and scrub the claim again to try to spot any obvious errors. Compare against claims that were successfully paid to spot any easy fixes.
In most cases, you don’t need to submit an appeal for small mistakes. Instead, submit a correction. A good rule of thumb is that appeals should never account for more than 5% of your total claims submitted.
Save appeals for cases where you know you have done everything right, and you have a clinically necessary diagnosis, but a claim is denied without cause.
2. Not Sure Why a Claim Was Rejected? Do Some Detective Work
Often, claims are denied for small things, but the insurance company may not reveal the specific edit triggering the denial. This happens all the time.
Here is an example: A patient came in for TMS treatment with PTSD symptoms and was diagnosed with Major Depressive Disorder (MDD). This is a common comorbid coding combination. TMS treatment was provided for MDD, but the claims were submitted with PTSD as the primary diagnosis code and MDD listed as the secondary.
Although MDD is a medically necessary diagnosis code for TMS treatments, the claims were repeatedly denied as “non-covered” or “information submitted is insufficient for services rendered.”
Unsure why, the billing team called the insurance representatives. They were told to submit a letter of medical necessity to overturn the denial. A better solution in this case, though, is to simply update the diagnosis code reported on the claim.
Because the TMS treatment was ordered and rendered for treatment of Major Depressive Disorder, the billing team removed the PTSD code entirely. Once this correction was submitted, the claim was processed in 14 days.
To spot potential fixes like this, Gentem uses automation and AI to review historical data from your practice and similar practices. We look for where claims are being systematically denied and analyze why. We’ll flag small corrections that can make a big difference.
3. Systematically Clean Up Old Rejected Claims
Once you spot a consistent error, take the time to review old claims to see where else you may have made the same mistake. The revenue payoff from old claims is often worth the review.
Sometimes, patterns go unnoticed. Here are a few of the top reasons TMS claims are denied. When you look back through, you may be surprised to find certain procedures that you’ve never actually been paid for. Or, as in the example above, you can save yourself time by preventing denials and the time you spend responding to them.
Reviewing old claims can be tedious work. That’s why Gentem offers a clear dashboard to make the process easier, as well as a support team that can flag some of these things for you.
4. Appeal When You Have To
While many denials come down to small errors, sometimes an appeal really is necessary.
Again, save appeals for when you have a clinically necessary diagnosis code, and a claim is being denied without a factual basis. Once you are certain that your claim is error-free, you should move onto the appeals stage.
When you appeal, you will write an effective letter that restates both the payer’s policy and why your claim should qualify. You will also attach supporting documentation.
In an appeal, your goal is to represent your practice and make the strongest possible case for your claim. With TMS, that usually means beefing up your documentation so it clearly meets the payer’s standard as well as the standards of your practice.
For TMS in particular, you may need to explain the underlying factors contributing to a diagnosis of Major Depressive Disorder. Any chronic or complex conditions should be included.
5. Know When to Invoke State Parity Laws
Because TMS is a behavioral health procedure, some payers may not want to pay. But in many states, parity laws state that behavioral health claims need to be treated the same as medical claims. Under those laws, insurance companies can’t create one-off exclusions or apply stricter criteria.
Even so, some payers with strict program integrity reviews will still aggressively deny claims, and some may do so inappropriately. Invoking state parity laws is a last line of defense. It is a time consuming process, and only relevant in a tiny fraction of cases.
Claims that legitimately make it to this stage are usually approved; the key is to avoid getting to this point. Most issues should and can be resolvable with a correction or an appeal.
Still, you still may want to familiarize yourself with your state’s parity laws so you know what to look out for. Sometimes, that knowledge can come in handy if you want to let payers know earlier in the process that you are well versed in your state’s payer legislation, TMS, and the right to reimbursement.
It is the biller’s responsibility to make sure claims are paid and that the practice receives the revenue they deserve for the treatment provided. Claim corrections, appeals, and parity laws are all useful tools. If you need backup, Gentem can help.