One of the most common and frustrating obstacles in healthcare billing is dealing with denied claims—especially those tagged with Reason Code M86 denials. This denial states: “Service denied because payment already made for same/similar procedure within set time frame.” For healthcare providers, understanding why this happens and how to prevent it is crucial to maintaining a healthy cash flow and seamless patient experience.
Let’s break down what causes an M86 denial and how you can proactively prevent and resolve it.
What Triggers an M86 Denials?
An M86 denial often indicates that the payer sees the billed service as either already paid or too similar to a previously paid claim. Common culprits include:
- Duplicate Billing: Accidentally submitting the same claim twice.
- Bundled Services: The procedure is part of a previously paid service.
- Non-Covered Services: The service isn’t included in the patient’s benefits.
- Exceeded Limits: The patient hit their plan’s annual or lifetime limits.
- Coverage Rules: Policies that limit same-day visits or consultations.
- Incorrect Details: Missing patient info, wrong codes, or date mismatches.
- Lack of Documentation: Missing proof of medical necessity.
Proven Strategies to Prevent M86 Denials
To avoid revenue disruption, implement these tactics:
- Audit Before Submission: Double-check that the service hasn’t already been billed.
- Use Correct Modifiers: Clearly distinguish separate services on the same day.
- Confirm Coverage First: Know exactly what’s included in the patient’s plan.
- Train Your Team: Stay updated on payer-specific billing rules.
- Update Practice Management Systems: Use tech to flag duplicates before submission.
- Enhance Documentation: Provide clear, justified reasons for the service.
- Open Communication: Talk with payers to clarify unclear denials.
The Claims Med Edge
Tired of fighting M86 denials alone? Claims Med can help.
Our revenue cycle experts specialize in denial management and payer relations. We streamline your billing process, ensure coding accuracy, and help your team stay compliant with the latest industry standards. With Claims Med by your side, you’ll reduce denials, speed up collections, and boost your practice’s profitability.
Let’s Talk About Your Denials
Don’t let claim rejections slow you down. Contact Claims Med today and let’s turn those denials into dollars.