Medical claims represent a significant portion of your practice’s revenue. And, what’s worse is that medical claim denials and rejections mean lost revenue and wasted money. 

According to a survey mentioned in Becker’s Hospital CFO report, 24% of denials are related to eligibility concerns. Another American Medical Association study estimated the cost of insurance follow-up for registration difficulties to be approximately $19 per claim. Therefore, if a practice can minimize the number of eligibility denials by five per day, it can save $100 in administrative expenses.

The statistics are significant, and practices must take them seriously. The crucial word here is preventive. When a claim is denied, the practice has already wasted fifteen days, and in the healthcare industry, time is money. A doctor performs a service, say on the first of the month, but the payment will not reach the accounts receivable for around 30 days. Denial or rejection after this length of time is unappealing.

Provider services are distinct from other types of enterprises. If we leave a store after shopping, we are supposed to have paid. If cable companies do not receive payment in advance, they will discontinue service. The service is already offered, so healthcare providers cannot reduce it. You would want these claims to be resolved since they are crucial to the survival of your practice.

So, this blog will look at the ways that you can reduce claim rejection and denial in your medical practice.

Find Reasons for High Denial Rates

Investigating the factors that may be to blame for the rise in denial rates is the first step in lowering those numbers since it is also the one that makes the most sense. It varies greatly from practice to practice and specialty to specialty as to why they are so high denial rates. Thus, a denial management plan must begin with claim adjustment reason codes. Mapping these inconsistent and ambiguous symbols into actionable descriptors helps reveal the fundamental causes of the problem. Denial rates may rise due to:

• Unauthorized medical treatment
• Procedure or diagnosis code invalidity
• Duplicity of assertion.
• Claim filed late
• Incorrect insurer address
• Incorrect modifier
• Wrong patient names, dates, and insurance numbers
• Insufficient supporting evidence
• Invalid diagnosis codes or procedures
• Global charges instead of professional or technical charges
• Unwanted medical procedures
• Provider-restricted plan
• Payer requests patient information

Verify Eligibility

Eligibility concerns account for 24% of the overall number of denied applications. Verifying a patient’s eligibility should be your top priority if they have been coming to see you for multiple years. People’s jobs and sometimes even their plans can change, so it is important to keep track of these things. Every patient who walks through the door of practice should have coverage that has not been canceled, and their benefits should not have been exhausted. This is a requirement for practice.

The staff must be skilled enough to understand the policies of the plans you accept, have the ability to interpret those policies, and have enough self-assurance to discuss coverage with patients.

Gather Complete Information

Simply making one mistake can completely change the outcome of your claim. When filing claims, be aware that leaving even one field blank can result in a rejection of your request. Please ensure that the information you provide is accurate. 61% of medical billing denials and 42% of denial write-offs can be attributed to inaccurate plan codes and incorrect social security numbers.

It is essential to provide information that is complete and accurate. A significant amount of money can be lost on seemingly insignificant particulars. Pay careful attention to the specifics, such as the name, date of birth, insurance payer, policy number, and so on.

Implement Technology

Many practices are unable to employ or deploy practice management solutions. Some people think that they are too pricey and take up too much time. However, this does not mean that practitioners should ignore the opportunities presented by technological advancements. For instance, if you have access to a database, you can retrieve patient folders much more quickly than if you had to pick them out of disorganized file cabinets.

Before claims are sent out for final consideration, there are review systems available that come equipped with their own in-built edits. These kinds of tools can send out alerts to the employees and force them to make changes and go over the claims again and again until they get it right.

Share Denial Statistics

You can improve your chances of avoiding similar errors in the future by drawing lessons from your past experiences. During the course of the team meetings, the practices should make it a point to talk about the denials that have been issued. By itself, setting a goal for development can be as simple as sharing the rates of claim rejections and denials and being aware of the reasons for each.

Your team will be better able to differentiate between denials and rejections if there is an open flow of information like this throughout your organization. It will also make it simple for your team to learn how the issue arose in the first place and how to fix it so that it doesn’t happen again in future procedures.

Check Referrals, Authorizations, and Medical Necessities

Problems with authorizing and pre-certifying services are responsible for 18% of all denials. Learning which services are regarded to be “medically required,” which services require prior authorization, and which treatments require referrals takes some time. Additionally, having a previous authorization does not ensure that payment will be made. In addition to this, the claim needs to be supported by medical necessity, submitted before the time and submitted by the provider who was specified in the referral or authorization. Only carry out a procedure if there is a clear medical basis for doing so; this will ensure that you remain within the confines of medical necessity. Make notes or attach relevant paperwork to give evidence in support of the services rendered.

Ensure correct coding

Coding to the most specific level possible is the most effective strategy for lowering the number of claims that are denied. Because of this, coding is typically done up to the fifth digit. Your claim can be rejected if you are utilizing an out-of-date codebook, if your coder or biller inserts the wrong code, or if all of the above happen. Make sure that the chargemaster and diagnosis listing contain the most recent version of CPT, HCPCS, and ICD-10 codes if your practice relies on a hospital or another facility to provide procedure or diagnosis data. If your practice depends on a hospital or other facility for this information, your practice may be at risk.

Making false statements in order to obtain financial compensation for medical services becomes a criminal offence. Upcoding and unbundling are both included in this. Even “honest mistakes” have the potential to put you in danger. In order to lower your risk and responsibility, you should develop staff protocols.

Timely Claim Submission

When claims need to be submitted is a matter that is governed differently by each payer. Guidelines for commercial payers and those for Medicare are not the same. The editing of claims might result in delays, which can push submissions beyond the due date. In most cases, the claim will be rejected if it is submitted after the deadline has passed.

Develop procedures and reference documents in order to meet the timeframes set by payers. Include a workflow that will notify staff when the deadline for filing a claim is getting close. Organize a contest to determine who can file the most correct and timely claims on a weekly, monthly, quarterly, and annual basis in order to cut down on the number of claims that are denied.

Continuous Staff Training

Inadequate or outdated employee training techniques are a recipe for trouble. Regular and current staff training increases the administration of the practice and, as a result, creates a holistic and robust foundation for the success of an organization. A substantial cause of health insurance claim denials is staff error, which can be remedied by prioritizing medical coding staff training, executive seminars, and other relevant areas. A well-trained workforce eliminates data entry errors, is knowledgeable about insurance coverage and eligibility criteria, and can competently meet all paperwork requirements, hence decreasing medical billing denial rates.

Regular staff training may cost a certain sum of money, but it is essential to recognize the investment character of this expenditure. Trained personnel can easily minimize the large quantities spent on managing refused claims, thereby compensating for the initial sums invested in them. On the other side, you can swiftly wreck your practice by refusing to invest time, money, and effort in an untrained administrative staff.

Outsource to Save Time and Money

It might be challenging to manage claims while also lowering the percentage of claims that are denied or rejected. In addition, in order to complete this procedure, you will need to invest a sufficient amount of time and resources into the acquisition of both human and technological assistance. Because of this, outsourcing the process is now the greatest choice that may be considered for practice.

Not only does outsourcing to a reliable medical billing company like Aplus RCM can save money, but it also improves productivity. For instance, healthcare billing firms offer denial management services, through which dedicated specialists contact insurance companies to learn the reasons for claims being denied and to make changes. This, in turn, can help to improve the revenue cycle management healthcare process.

If you want to outsource your denial management to a reliable medical billing company you can always rely on Aplus RCM. 

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