By Francisco Francisco - Medicaid Eligibility Supervisor
November 2021
National Provider Identifier (NPI) claim denials continue to be an issue for many providers. These denials occur when services are rendered by providers not enrolled in the Medicaid program. From a glance, this seems like a straight forward issue to resolve, but the truth is that NPI denials can occur due to a number of reasons. NPI denials can range from missing NPI numbers, an inadequate combination of NPI and taxonomy codes for providers, or a lack of enrollment, just to name a few reasons. Understanding what causes NPI denials and being proactive in identifying them in a timely manner can go a long way to reducing lost revenue.
One common reason that leads to these denials is a non-Medicaid-enrolled physician at an organization. To give an example, CBIZ worked with a client that had a behavioral health doctor who was not enrolled in Medicaid, although the physician treated a significant number of their psych patients. We were tasked with looking into the matter and we identified that there was a list of denied NPI claims associated with that physician. In addition, we discovered that the doctor WAS enrolled in Medicaid after the dates of service which were denied. In this example, we were able to obtain retroactive reimbursement and were able to recover all of the claims under that physician, resulting in $483,000 in payments for our client.
The potential benefits for addressing NPI denial claims don’t stop at the payment you receive for denied claims. In reality, the real benefit is making sure that the number of future claims under those same non-enrolled physicians are paid in a timely manner. It is important to note that a physician does not need to be enrolled in the Medicaid program to resolve these NPI denials; they can choose to complete the required paperwork for billing purposes only. In short, providers can treat Medicaid FFS beneficiaries without the contractual agreement of a participating provider.
Over the last few years CBIZ has conducted extensive research on NPI denials and has assisted a number of clients with reducing them. The reasons for these denials aren’t always as clear-cut as it would seem on the surface. While providers can appeal and recover revenue from many of these denied claims, we have found that even with their best appeal efforts, they may still lose a considerable amount of money (six or seven-figures, annually) if these issues aren’t fixed on a go-forward basis.
Resolving the different types of NPI denials often requires significant experience. These denials can be time-intensive issues to address, but it is absolute vital to allocate the appropriate time and resources to reduce these denials and the lost revenue associated with them.
If you have any questions about NPI denials and would like to learn more about how CBIZ has assisted clients in this area, please contact Juan Chico at jchico@cbiz.com or at 609-918-0990.
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