Medical claim denials are a part of the process. However, you must be concerned when the rate of denials exceeds your expectation. Recent data from the Healthcare Information and Management Systems Society (HIMSS) survey shows that 3 out of 4 healthcare leaders emphasize denials as the most significant challenge. Interestingly, two-thirds of them are recoverable.
The primary factor behind this is due to a poorly managed claim process. It’s harmful to the financial health of the practice. o naturally, the accountability of claim denials falls on a billing team. Now, everyone in practice must claim part of the responsibility in avoiding denials.
When you hire revenue cycle management services, the agents divide it into two phases, pre, and post-claim. Here, pre-claim includes registration, charge entry, scrubbing, coding, and clearinghouse submission.
Post claim is when the suit gets processed, paid, or denied. Then, it gets posted and closed or directed to Accounts Receivables to be worked and appealed. During the pre-claim phase, the revenue cycle management services work on the insurance and demographic information. Here, the provider sees the patient’s documents and codes the notes.
The addition of superbills and handing it off to scrub for accuracy modifies, and QC is carried. In case there’s an issue or things are done incorrectly, a denial may be received. If the denials happen and no one follows them, the money gets written off. The healthcare debt recovery services ensure the medical claims are as clean as possible the first time around.
To begin with, you must understand some of the most common reasons behind denials.
Eligibility
Before the patient is ever seen, the staff must verify the eligibility. Revenue cycle management services confirm whether coverage is still active or not. You must be in the network of approved providers.
Authorization
Does the patient need a pre-authorization or referral before services are rendered? Not obtaining one can cost both you and the patient. In addition, you must partner with reliable healthcare debt collection agency which ensure this process gets done correctly.
Claim form errors
Claim denials do occur due to simple clerical errors. Now can be in terms of misspellings or ID number transposition. In addition, it might miss pertinent information such as the date of accident or date of onset.
Coding errors
Did the wrong code get entered on the claim? There might be upcoding or unbundling. Should there be a modifier, or was the wrong one used? These are some of the concerns that lead to coding errors.
Claims no filed in time
Each insurer has a timeline for when a claim needs to be filed once a patient has been seen. Not understanding those timelines leads to denial and slows down revenue generation.
Duplicate claim
Someone may submit a second claim when reimbursement has not been received. Not only is there a reduction in revenue from the patient’s service, but there are also costs associated with reworking claims that have been denied. With revenue cycle management services, you don’t have to worry about such issues.
Medical claims denials
The good news is that healthcare debt recovery services can reduce the number of denials received every month. Making real changes in the number of denials will require re-thinking the entire revenue cycle. Here are a few ways to decrease denial rates:
- Do not miss reviewing detailed monthly reports
- Sort summary of denial by most denied reason to determine where to make the most significant impact
- Self-train on denial reasons and code and guideline changes
Final Wrap
Outsourcing revenue management services increases the number of clean medical claims being submitted with less stress on the staff. Get help from the experts today to sort all the issues regarding claim denials.
