Claims get denied all the time and this is the single biggest headache for medical billers. Because medical appeal cases focus on rejected claims, a significant factor that directly influences the revenue cycle healthcare providers is claim denials. As medical claim denials happen, some part of the revenue cycle slows down and recovery can take a long, thereby increasing the expense of administration and of course, it can delaying the payment. Upping the revenue cycle process with better operations and efficiency of the medical practice by reducing billed claims can benefit medical practices in optimizing the revenue cycle. Less hassle in healthcare billing, maximum reimbursements, fewer claims rejections, fewer call-backs for payment balances, quick recoveries from the payment sources, and smooth operations are some of the best practices that can be implemented in medical practice to improve the claim acceptance rate.
1. Understand the Common Reasons for Medical Claim Denials
Reasons for denied claims include:
- Patient setup error: Incorrect information about the patient, such as data related to demographics, insurance, or insurance policy number.
- coding errors: inaccurate medical coding based on regulations or old codes can lead to claim denial.
- Errors in billing codes: For example, coding errors in specialist practices – such as endocrinology billing and coding – often result in claims being denied.
Knowing what are the most common reasons why your claims get denied allows you to develop plans to prevent them from happening again in your office, review trends in the rejection of your claims – and take advantage of reporting tools – to identify problem areas early on.
2. Improve Medical Billing Accuracy
Further rejection of claims can be reduced by making sure that medical billings are correct: that all information about the patient is entered correctly, and that the number of ‘medical encounters’ accurately corresponds to the number of codes billed.
Verify patient information: Incorrect or missing patient data is the number one reason for medical bill denials. It’s essential to verify all patient demographic information, insurance coverage, and policy numbers at every visit. Confirming the patient’s details are correct and matching the payers’ requirements helps to minimize denials.
Coders must not only understand the rules behind each code but also know what correct coding looks like:
- Accuracy – Accurate and current coding is crucial for approving claims. Ensure that CPT, ICD-10, and HCPCS codes are accurate when provided by your coders. This is especially important in niche areas of billing and coding, like endocrinology billing and coding. As where accurate and detailed coding is vital as documentation requirements can vary significantly between practices. An error in a procedure code or a miss in the diagnoses section of your claim could leave you with a backlog of denials
- Keep codes current – Ensure that your EMR or Coding Clearinghouse has the most recent updates to avoid problems.
Such training of billing staff and the use of automated billing systems with extensive in-build error-detection measures are an answer to this problem of skewed billing leading to claim rejections and due to coding issues.
3. Conduct Pre-Claim Eligibility Verification
Many claim denials come back because the patient’s insurance is not active or does not apply to the service or procedure provided. This makes the pre-authorization or pre-certification of eligibility an essential step to prevent a claim denial down the road.
- Check your insurance information: Make sure the data on your patients’ insurance policies is up to date. Many insurance companies make changes in their policies on an annual basis, especially. When it comes to coverage or eligibility issues, which can trigger the rejection of your claim.
- Check for pre-authorization: Certain services require prior approval from the insurance company before they are performed (eg, some middle-range surgeries, many scans, and most specialized services). If a claim is submitted for procedures that were not pre-authorized by your insurer, it may be denied. Checking about pre-authorization before having specialized appointments will help you to make sure that you do not have payment delays, and might eliminate the chance of a denial.
4. Stay Updated on Denial Codes and Trends
Identifying denial codes is also important to help claims be paid in the first place. For instance, CO 9 denotes a ‘Service not covered by member’s insurance plan or member has been paid atMaximumLimits’.
Use denial codes to study reasons behind denials: Most industries have an accepted standardized language. So which it communicates, and healthcare is no exception. By analyzing the most common denial codes, such as the CO 9 denial code, a healthcare provider can uncover areas where claims are being denied, and tweak those operations. By tracking the patterns of denial codes, your team can ensure it is zooming in on areas of problems. For which it can take the necessary corrective steps and prevent similar problems in the future.
With regular staff training: billing staff should go through recurrent training regarding the identification of denial codes. However each one of them can be addressed promptly and properly. Therefore, ensuring revenues will not be lost by a slow reaction and ensuring proper tips on revenue recovery.
5. Timely and Accurate Documentation
One thing that will help complete claims and get them paid quickly is good documentation. Probably if there was an error in the documentation the insurance would deny it because they wouldn’t have enough information.
- Keep good medical records: Any service that gets billed has to be recorded in the patient’s chart. If the reimbursement form codes don’t match the medical record documentation, it is denied. The better your medical records, the less likely the visit will end in a coding discrepancy.
- Timely claim submissions: Delayed submission of claims increases the risk of denials. Healthcare billing teams should make every effort to submit claims as quickly as possible following the provision of services. Software systems that automatically track deadline submission dates can help ensure that a claim is not rejected due to its being filed late.
6. Appeal Denied Claims Promptly
Despite best efforts, medical claims can be denied. Developing a successful denial management policy is vital to appealing rejected claims and recapturing lost revenue.
- Review and appeal claims denied: Medical billing staff should review denied claims and then appeal them as quickly as possible. Be sure you understand the reason for the denial and collect all of the documentation in support of your appeal before submitting it.
- Track appeal results: Track the results of appeals, such as how often they succeed, so you can identify trends. If you track why an appeal is winning or losing, then you can improve your billing processes and reduce the rate of denials going forward.
Conclusion
Medical billing denials can be reduced with a proactive strategy of improved billing accuracy. Although verification of insurance eligibility, denial codes awareness, and efficient workflow. Whether you are performing endocrinology billing and coding, or performing claims submitted to an urgent care center. Or anything for your medical billing organization, implement these best medical billing practices to improve the acceptability of your claims, and timely revenue recovery. And reduce claim rejections with improved practice-specific claims turnaround.
