Denial code 195 is used when a refund has been issued to a payer who was mistakenly identified as the primary payer for the claim or service. This means that the payment was sent to the wrong payer and needs to be corrected.
Common causes of code 195 are:
1. Incorrect billing: This code may be triggered when a refund is issued to a priority payer that was mistakenly billed for the claim or service. It could occur due to human error, such as selecting the wrong payer or entering incorrect billing information.
2. Duplicate billing: Code 195 can also result from duplicate billing, where the same claim or service is submitted to multiple payers. If a refund is issued to one of the payers in error, this code may be assigned.
3. Payer coordination issues: In some cases, code 195 may indicate a problem with payer coordination. For example, if a claim is initially submitted to one payer but should have been sent to a different priority payer, a refund may be issued to correct the error.
4. System or software glitches: Occasionally, technical issues with billing systems or software can lead to code 195 denials. These glitches may cause incorrect payer information to be associated with a claim, resulting in a refund being issued to the wrong priority payer.
5. Lack of documentation: Insufficient documentation to support the claim or service can also lead to code 195 denials. If the payer determines that the claim was not valid or lacked necessary documentation, a refund may be issued to the priority payer.
6. Changes in payer policies: Payer policies and guidelines can change over time, and if the billing process does not adapt accordingly, it may result in code 195 denials. For example, if a payer's priority status changes, but the billing system continues to send refunds to the previous priority payer, this code may be assigned.
It is important for healthcare providers to review their billing processes, double-check payer information, and ensure accurate documentation to minimize the occurrence of code 195 denials.
Ways to mitigate code 195 include:
- Double-checking payer information: Ensure that the correct priority payer is identified before submitting the claim. Verify the payer's name, address, and any specific requirements or guidelines they may have.
- Accurate patient information: Ensure that all patient demographic information is accurate and up to date. This includes the patient's name, date of birth, insurance policy number, and any other relevant details. Inaccurate patient information can lead to claims being sent to the wrong payer.
- Thoroughly reviewing claims before submission: Take the time to carefully review each claim before submitting it. Look for any errors or inconsistencies that could result in a denial or incorrect payment. This includes checking for duplicate claims, missing or incorrect procedure codes, and incomplete documentation.
- Utilizing electronic claim submission: Electronic claim submission can help reduce errors and improve efficiency. It allows for real-time validation of claims, ensuring that all required fields are completed and accurate. This can help prevent claims from being sent to the wrong payer.
- Regularly updating payer information: Stay informed about any changes or updates to payer information. Payers may change their addresses, contact information, or specific requirements over time. Regularly updating this information in your system can help prevent claims from being sent to the wrong payer.
- Implementing a robust claims management system: Utilize a comprehensive claims management system that includes built-in checks and balances. This can help identify potential errors or issues before claims are submitted, reducing the likelihood of denials or incorrect payments.
- Training and education: Provide ongoing training and education to staff members involved in the revenue cycle management process. This includes training on payer requirements, claim submission best practices, and how to identify and resolve potential issues that could lead to denials.
By implementing these strategies, healthcare providers can mitigate code 195 and reduce the likelihood of issuing refunds to erroneous priority payers for their claims/services.
The steps to address code 195, which indicates a refund issued to an erroneous priority payer for this claim/service, are as follows:
1. Review the claim details: Carefully examine the claim and associated documentation to ensure accuracy. Verify the payer information, patient details, and service provided.
2. Identify the erroneous priority payer: Determine which payer received the refund in error. This could be a result of a data entry mistake or a system error.
3. Contact the payer: Reach out to the payer that received the refund incorrectly. Explain the situation and provide them with the necessary details, such as the claim number and the reason for the refund error.
4. Request a refund reversal: Ask the payer to reverse the refund and return the funds to the appropriate payer. Provide any supporting documentation or evidence that supports your claim.
5. Document all communication: Keep a record of all interactions with the payer regarding the refund issue. This documentation will be useful for future reference and potential appeals.
6. Follow up: Monitor the progress of the refund reversal request. If the payer does not respond or fails to reverse the refund, escalate the issue to a higher authority within the payer organization.
7. Update internal processes: Analyze the root cause of the refund error and implement measures to prevent similar mistakes in the future. This may involve enhancing data entry protocols, improving system checks, or providing additional training to staff members involved in the revenue cycle management process.
By following these steps, healthcare providers can effectively address code 195 and rectify the issue of a refund issued to an erroneous priority payer for a claim or service.