One of the most challenging situations a healthcare facility can face is claim denial from insurance companies. Denials need to be addressed promptly for timely reimbursement. According to the American Medical Association’s (AMA) recent report on the National Health Insurer Report Card, health insurance companies pay 0 percent of the payment for 23% of the claims submitted. The most common denial is the CO-45 denial.
This blog will help you better understand what CO-45 denial is. What are the common causes, their impact on the healthcare provider, strategies to resolve them, and successful appeal filing methods?
Also Read: A Comprehensive Denial Management Guide
Understanding CO-45 Denial Codes
The CO-45 Denial Code is the denial from the insurance company because the provider’s claim charge exceeds the fee schedule in a contract between two entities. The CO stands for contractual obligation, which means a mutual agreement is held between a healthcare provider and an insurance company.
For example, if the fee of a dialysis procedure is $200 in a contract, but the provider charges $250, the insurance company will deny the claim with a CO-45 code. This has a direct negative impact on the financial aspects of the healthcare organization. The healthcare provider will not receive reimbursement for these denied services.
Common Contractual Obligations
Here is a list of common contractual obligations frequently occurring because the insurance company refuses to pay. Each contractual obligation is denoted by a specific code with an identifier:
Duplicate Billing Code CO-18: Insurance companies deny this claim because it is duplicated, and the same claim is already submitted.
Benefit Inclusion Code CO-97: The claim is rejected because the claim is already adjusted for payment in another service claim that is already reimbursed.
Missing Information Code CO-16: The healthcare payer denied the claim because it lacked the necessary information to process it.
Unestablished Medical Necessity Code CO-50: This denial occurs because the claim does not fulfill the definition of an insurance company’s medical necessity.
Coordination of Benefits Code CO-22:
The claim is denied because another insurance company covers the service due to the coordination of benefits. Thus, the claim is denied.
|Denial Code||Denial Reason|
|CO-45||Claim charge exceeds the fee schedule in a contract|
|CO-50||Service is not considered as a medical necessity by insurance companies.|
|CO-22||Another Insurance Company covers service|
|CO-16||Lack necessary documentation|
|CO-24||Service is not aligned with modifier used|
|CO-18||Service is duplicated|
|CO-109||Service exceeds the time/hours/days|
Causes of CO-45 Denials
The CO-45 denial occurs due to various reasons. Some common causes include:
Service not Covered: The patient’s insurance policy does not cover some services. The claim is denied due to the non-coverage.
Prior-Authorization Requirement: Some services and procedures demand approval from healthcare payers. If a healthcare provider fails to get prior authorization for assistance, the claim is denied with code CO-45.
Policy Restriction: Some insurance policies have limitations, such as time limits, age limits, etc. Healthcare providers must fulfill this criterion; otherwise, denial is possible.
Coding Error and Lack of Documentation: Inaccurate coding and a lack of documentation are the primary reasons behind claim denial. Wrong codes lead to the wrong classification of services, which results in CO-45 denial. The claim is denied if the documents do not justify the procedure’s medical necessity.
The Impact of CO-45 Denial on Healthcare Providers
The CO-45 denial in medical billing and coding substantially affects healthcare providers. The implications are the following:
Financial Loss: The healthcare provider faces financial loss as the CO-45 denial results in delayed or reduced payments. The cash flow of the healthcare facility is brutally affected.
Increased Overhead Cost: Extra time and staff are required to manage denials from the insurance companies. This increases the overhead cost of the healthcare facility.
Operational Efficiency: Continuous denials such as CO-45, CO-22, and CO-97 raise questions about the operational efficiency of the billing process.
Administrative Burden: Administrative efforts are required to handle the denials, find the error, verify the documentation, and initiate the appeal process.
Impact on Provider’s Reputation: The provider’s reputation is at stake after multiple denials for different errors. The denial challenges may reflect the overall service quality of the healthcare provider.
How to Resolve CO-45 Denials?
Different strategies can be utilized to resolve the issue of CO-45 denials for timely reimbursement. A list of effective strategies is summarized below:
Verify documentation before submission.
Verify the availability of all the medical records and documents related to the submitted claims. Documents should be clear and updated with the latest changes and guidelines. It must justify the medical necessity and support the procedure.
Utilization of Modifier
The coder must know the necessity of using a modifier where necessary. He must check whether the modifier must provide all the related information. Sometimes, the use of modifiers resolves the issue of CO-45 denials.
Utilization of Modern Software
The healthcare provider utilizes billing software that is automated to resolve all the billing and coding errors. They have in-built checkpoints to resolve denials, such as CO-45. The utilization of this software acts as a barrier to identifying and resolving errors before the submission of the claims.
Review Denial Details
Understand the significant reason behind the CO-45 denial. Thoroughly review the denial details, such as the explanation of benefits (EOB), the modifier used, the accuracy of the codes, and the reason provided by the healthcare insurance company.
Reach out to the Healthcare Payer
Please communicate with the insurance company to understand their concerns and clarify any uncertainty about the denial reasons. Direct interaction between the two entities resolves misunderstandings and helps find an easy solution.
By employing the above-mentioned strategies, one can successfully avoid contractual obligation denials. This leads to accurate reimbursement for the healthcare facility.
How to File a Successful Appeal for CO-45 Denial?
Filing a successful appeal for CO-45 denial faces some challenges along the way. Here is an easy step-by-step guide that can help you in the process:
Step # 1 Understand the Reason behind Denial
The first step is to review the explanation of benefits (EOB) to understand the primary reason behind the denial.
Step# 2 Gather Supporting Documents
Verify the supporting documents required for the appeal. This includes the medical record, progress notes, and all other documentation.
Step # 3 Review Modifiers and Coding
Ensure that accurate coding is done and modifiers are used where necessary. Verify if the coding procedure has followed the guidelines of the regulatory bodies.
Step # 4 Write an Appeal Letter
Write a concise appeal letter with all the necessary information, such as the patient’s information, the services rendered, and the reason for the appeal.
Step # 5 Explain Procedure Relation
Explain the reason why the proposed bills are not mutually exclusive. Why every service has a distinct purpose and how they do not overlap.
Step # 6 Submit the Appeal
Following the guidelines provided by the insurance company, submit the appeal letter within the timeframe.
Step # 7 Follow-Up
Following up with the healthcare payer is mandatory to check the appeal status.
In conclusion, it is safe to say that CO-45 denial is the most common denial in revenue cycle management. It occurs when the submitted claim charge exceeds the fee schedule in an agreement between the healthcare provider and the insurance company. Strategies listed in this blog can help anyone struggling with CO-45 denial.
If you are facing the intricacies of CO-45 denials, outsourcing to a medical billing company such as Medheave is the best and most workable solution for you. Medheave covers everything from claim submission to handling denials. Contact us now and resolve your headache of CO-45 denials.