PR-85 Denials Explained: How to Identify, Appeal, and Prevent Them

Denial codes are a persistent challenge for healthcare revenue cycle management (RCM) teams, and PR-85 is no exception. This code pertains to patient interest adjustments, which can create confusion and delays if not handled effectively. For organizations striving to optimize collections and reduce accounts receivable days, understanding PR-85 denials is critical.

In this article, we’ll break down the specifics of PR-85 denials, compare them to similar codes, explore their causes, and provide actionable guidance on appealing and preventing them.

What Is a PR-85 Denial?

The PR-85 denial code represents a "Patient Interest Adjustment," indicating that the adjustment is tied to interest charges on a patient’s unpaid balance. The prefix "PR" in the code stands for "Patient Responsibility," meaning the patient is financially responsible for the interest amount.

It’s essential to differentiate PR-85 from other adjustment prefixes:
- PR (Patient Responsibility): The patient owes the amount.
- CO (Contractual Obligation): The adjustment is due to payer-provider agreements.
- OA (Other Adjustment): Miscellaneous adjustments.

In the case of PR-85, the financial responsibility lies solely with the patient, and providers must determine how to collect payment or address disputes efficiently.

Comparison: PR-85 vs Similar Denial Codes

Denial Code	Prefix Meaning	Reason/Description	Who's Financially Responsible
PR-85	Patient Responsibility	Interest charges on unpaid patient balance	Patient
PR-1	Patient Responsibility	Deductible amount	Patient
CO-45	Contractual Obligation	Charge exceeds contracted fee schedule	Payer

While PR-85 focuses on interest charges, codes like PR-1 and CO-45 relate to other forms of patient or payer adjustments. Understanding these distinctions helps RCM teams address denials more effectively.

Common Causes of PR-85 Denials

1. Delayed Patient Payments: Patients failing to pay balances on time can accrue interest, leading to PR-85 denials.
2. Incorrect Interest Calculations: Errors in calculating interest charges result in disputes and denials.
3. Lack of Transparency: Patients unaware of interest policies may refuse to pay or dispute charges.
4. System Errors: Billing system misconfigurations can apply interest erroneously, triggering denials.

Impact on Revenue Cycle Teams

PR-85 denials pose both financial and operational hurdles for healthcare organizations:

Financial Impact:

• Lost revenue due to unresolved denials and unpaid interest.
• Increased accounts receivable (A/R) days, straining cash flow.
• Write-offs of interest charges if appeals fail or deadlines are missed.
• Higher costs from reallocating resources to manage denials.

Operational Impact:

• Time-consuming denial management processes divert attention from other critical tasks.
• Teams must stay informed about payer rules and documentation requirements.
• Coordination between billing, coding, and patient-facing departments is required.
• Tracking denial patterns and outcomes demands ongoing effort.

To mitigate these challenges, organizations can leverage CombineHealth.ai’s AI-driven solutions such as Adam, the AI Denial Manager, to track and manage PR-85 denials efficiently. Adam’s capabilities help reduce financial loss and streamline operational workflows.

Steps To Appeal a PR-85 Denial

Step 1: Review the Denial Notice
Carefully examine the denial details to confirm it pertains to a PR-85 adjustment.

Step 2: Gather Documentation
Compile relevant billing records, interest calculation details, and patient correspondence.

Step 3: Verify Eligibility
Check payer policies and ensure the interest charges were applied correctly.

Step 4: Prepare Appeal Letter
Draft a formal appeal letter citing the denial reason, supporting documentation, and a request for reconsideration.

Step 5: Submit Within Deadline
Ensure the appeal is filed within the payer’s specified timeline to avoid automatic rejection.

Step 6: Track and Follow Up
Monitor the appeal status regularly and follow up with the payer as needed for resolution.

How To Prevent PR-85 Denials

Front-End Prevention

• Educate Patients: Inform patients about interest policies at the time of service.
• Accurate Billing Practices: Ensure interest charges are calculated and applied correctly.

Billing Best Practices

• Clear Communication: Send timely reminders and detailed statements to patients.
• Interest Policy Disclosure: Include interest-related terms in financial agreements upfront.

Technology Solutions

• Automated Eligibility Verification: Use tools like CombineHealth.ai’s platform to confirm patient balances and avoid unnecessary interest charges.
• Real-Time Claim Scrubbing: Leverage Adam to detect potential billing errors before claims submission.

CombineHealth.ai’s advanced technology streamlines denial prevention through automation and AI-powered insights. Rachel, the AI Appeals Manager, ensures appeals are managed effectively and expeditiously, reducing turnaround times and improving success rates.

FAQs

Q1: What does PR-85 mean in medical billing?
PR-85 indicates a Patient Interest Adjustment for interest accrued on unpaid balances, with the patient being financially responsible.

Q2: Can PR-85 denials be appealed?
Yes, PR-85 denials can be appealed by verifying the interest charges, gathering documentation, and submitting an appeal to the payer.

Q3: How long do I have to appeal?
Appeal deadlines vary by payer, but it is critical to act promptly, often within 30-60 days of the denial notice.

Q4: How can I prevent these denials?
Educating patients, using accurate billing practices, and leveraging AI-powered tools like Adam and Rachel from CombineHealth.ai can help prevent PR-85 denials. See our complete guide on denial prevention.