Denial code 24, Charges are covered under a capitation agreement/managed care plan, often arises when healthcare providers submit claims to Original Medicare for services that should be billed to a Medicare Advantage plan. This typically occurs when a patient’s healthcare coverage is primarily through a Medicare Advantage plan, which is administered by a private insurance company.
Capitation Agreements and Medicare Advantage
A capitation agreement is a contractual arrangement between a healthcare provider and a managed care organization (MCO), such as a Medicare Advantage plan. Under this agreement, the provider receives a fixed fee per patient per month, regardless of the services rendered. This means that the MCO assumes the financial risk associated with patient care.
Medicare Advantage plans offer comprehensive coverage, including hospital insurance (Part A) and medical insurance (Part B). In most cases, these plans replace Original Medicare. However, there are exceptions, such as hospice care, which is still covered by Original Medicare even when a patient has a Medicare Advantage plan.
Common Reasons for Denial Code 24
Several factors can lead to denial code 24:
- Incorrect Claim Submission: Claims are often submitted to Original Medicare instead of the Medicare Advantage plan.
- Plan Discrepancies: Mismatches between the insurance plan on file and the patient’s actual coverage can result in denials.
- Insufficient Documentation: Lack of adequate documentation to support the charges can lead to denials.
- Prior Authorization Issues: Some capitation agreements or managed care plans require prior authorization for certain services. Failure to obtain this can result in denials.
Best Practices to Avoid Denial Code 24
- Verify Insurance Coverage: Always verify a patient’s insurance coverage before providing services.
- Coordinate Benefits: Ensure that coordination of benefits (COB) information is up-to-date to avoid double billing.
- Accurate Coding: Use correct coding guidelines to ensure accurate billing.
- Obtain Prior Authorization: When required, obtain prior authorization for services to prevent denials.
- Complete Documentation: Maintain comprehensive and accurate documentation to support claims.
- Appeal Denials: If a claim is denied, promptly review the reason and appeal if necessary.
Partner with Claims Med for Revenue Cycle Management
By understanding the nuances of capitation agreements and Medicare Advantage plans, healthcare providers can significantly reduce their risk of denials due to code 24. Partnering with a reputable revenue cycle management (RCM) firm like Claims Med can provide invaluable support in navigating these complexities. Our experts can help you streamline your billing processes, improve claim accuracy, and maximize your revenue.
Contact Claims Med: Reach out to Claims Med for tailored assistance in addressing Denial Code 24 and improving your revenue cycle management. Our experts provide comprehensive revenue cycle management solutions to help healthcare providers reduce denials and maximize reimbursements.