Denial code 85 is "Patient Interest Adjustment (Use Only Group code PR)". This means that the claim has been denied because the patient's interest adjustment has been applied. The adjustment could be related to any interest charges or fees that the patient may have incurred.
Common causes of code 85 (Patient Interest Adjustment) are:
- Late payment: The insurance company may have delayed the payment, resulting in additional interest charges being applied to the patient's account.
- Billing errors: Incorrect billing information or coding errors can lead to delayed payments and subsequent interest charges.
- Uncovered services: If the insurance company determines that certain services are not covered under the patient's policy, any interest charges related to those services may be the patient's responsibility.
- Non-compliance with payment terms: If the patient fails to make timely payments or does not adhere to the agreed-upon payment terms, interest charges may be applied.
- Disputed claims: If there is a dispute between the healthcare provider and the insurance company regarding the payment or coverage of services, interest charges may be incurred until the issue is resolved.
- Denial of claims: If the insurance company denies a claim, resulting in the patient being responsible for the payment, any interest charges may be applied until the outstanding balance is settled.
- Inadequate insurance coverage: If the patient's insurance policy has limited coverage or a high deductible, it may result in higher out-of-pocket expenses and potential interest charges.
- Delays in claim submission: If there are delays in submitting the claim to the insurance company, it can lead to delayed payments and subsequent interest charges.
- Incomplete or missing documentation: Insufficient or missing documentation required for claim submission can result in delayed payments and potential interest charges.
- Coordination of benefits issues: If there are coordination of benefits issues between multiple insurance providers, it can lead to delays in payment and potential interest charges.
Ways to mitigate code 85 (Patient Interest Adjustment) include:
- Accurate documentation: Ensure that all patient information, including insurance details and treatment records, is accurately documented. This will help prevent any discrepancies that could lead to interest adjustments.
- Timely claim submission: Submit claims in a timely manner to avoid any delays or denials. Late submissions can result in interest adjustments, so it is crucial to adhere to the designated timelines for claim filing.
- Thorough verification of benefits: Before providing any services, verify the patient's insurance coverage and benefits. This will help identify any potential issues or limitations that could lead to interest adjustments.
- Clear communication with patients: Maintain open and transparent communication with patients regarding their financial responsibilities. Clearly explain any potential interest adjustments that may occur and address any concerns or questions they may have.
- Compliance with coding guidelines: Ensure that all coding is accurate and compliant with the current coding guidelines. This will help prevent any coding errors that could result in interest adjustments.
- Regular staff training: Provide regular training sessions to your staff to keep them updated on the latest billing and coding regulations. This will help minimize errors and reduce the likelihood of interest adjustments.
- Utilize technology solutions: Implement advanced revenue cycle management software that can help identify potential issues and prevent interest adjustments. These solutions can automate processes, improve accuracy, and reduce the risk of errors.
- Conduct regular audits: Perform regular internal audits to identify any potential issues or areas for improvement. This proactive approach can help identify and address any factors that may lead to interest adjustments.
By implementing these strategies, healthcare providers can mitigate code 85 (Patient Interest Adjustment) and minimize the risk of financial losses associated with this denial code.
The steps to address code 85 (Patient Interest Adjustment) are as follows:
1. Review the claim: Carefully examine the claim to identify any errors or discrepancies that may have led to the interest adjustment. This could include incorrect billing codes, missing documentation, or other issues.
2. Verify patient information: Ensure that all patient information, such as name, date of birth, and insurance details, is accurate and up to date. Any inaccuracies in this information can lead to claim denials or adjustments.
3. Check for coding errors: Review the coding used on the claim to ensure that it aligns with the services provided. Look for any potential coding errors or inconsistencies that may have triggered the interest adjustment.
4. Review documentation: Thoroughly review the supporting documentation for the claim, such as medical records, test results, and treatment notes. Ensure that the documentation clearly supports the services billed and justifies the charges.
5. Communicate with the payer: Reach out to the insurance payer to discuss the interest adjustment and seek clarification on the reason behind it. This can help in understanding the specific issue and finding a resolution.
6. Appeal if necessary: If you believe that the interest adjustment was made in error or unjustified, consider filing an appeal with the insurance payer. Provide any additional documentation or evidence to support your case and demonstrate that the adjustment should be reversed.
7. Implement preventive measures: Once the issue has been resolved, take steps to prevent similar interest adjustments in the future. This may involve improving coding accuracy, enhancing documentation practices, or conducting internal audits to identify and address any potential issues proactively.
By following these steps, healthcare providers can effectively address code 85 (Patient Interest Adjustment) and work towards resolving any related issues with insurance payers.