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How Can A Billing Specialist Help Avoid Claim Denials?

August 14, 2013

Number of claims denied in the healthcare industry is a mystery. Claims are getting denied due to various reasons, and moreover the graph is showing an upward movement. It has been observed that most denials are in excess of 20%. As per a recent survey in Georgia, the table below depicts percentage of denials by few insurance payers –

Aetna 15%
Kaiser Permanente 47%
John Alden Life Insurance 67%

Few common reasons for insurance denials:

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  • Claim denied for Missing / Additional information Any missing data/ information can easily be considered as a reason for insurance denial by the payers
  • Claim denied for Pre certification Insurance companies often require obtaining approval before providing services. In cases where pre certification procedures are not complied to, the claims would be denied or in certain cases can be partially paid
  • Claim Denied as Coverage terminated Insurance benefits need to be verified before rendering services
  • Claim denied as non-covered service It is viewed as poor customer service by the patient to bill them for non-covered charges without making them aware that they may be responsible for the charges prior to their procedure
  • Claim denied for late filing There is a timing window for filing insurance claims, hence even if a proper claim is submitted but not within the timing window it will result in claim denials
  • Claim denied as CPT – mismatch Entering a proper CPT code is an important responsibility of the biller. The CPT code needs to justify the service rendered, hence extra precaution needs to be taken while entering codes
  • Claim denied for being duplicate Hospitals or clinics after not getting any response from insurance carriers for a long time; often make the mistake of resubmitting the claim; instead of following the proper process of a follow up. This leads to duplication and hence denials requiring the entire process of refilling to be carried out again
  • Claim denied for being illegible Payers have started accepting electronic claims, but there are still few payers who follow the traditional method of paper filling. In such a case often printed claims become illegible as Payers find it difficult t006F scan them through their system hence leading to claim denials

It should be noted that denials are not bad debts and with proper refilling they can be reimbursed. It is the duty of the biller to maintain accuracy while filling claims, carry out proper follow ups and refill denials with necessary changes.

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What does a biller need to do to help avoid denials?

  • Necessary information needs to be collected before filing and submitting claims
  • Patient demographic and insurance details need to be accurately entered into the system
  • Patients require to be billed for their reasonable portions
  • Co pays, and deductibles should be dealt with appropriately
  • Be regularly updated about the latest reforms and apply them during the billing process
  • Patient’s insurance details and eligibility needs to be scrutinized accurately and in advance
  • All necessary checks need to made regularly before filling a claim
  • Timely appeals need to be made for denied claims
  • Correction and resubmission of denied claims can help recover revenue and also reduce chance of future denials

The medical biller needs to be a person with good math, multi-tasking and data entry skills. He should have a sound knowledge of reforms in the healthcare industry, CPT codes, insurance process and medical terminology to help avoid denials as much as possible. Hence a billing specialist is the best person who is in a position to be constantly updated and help achieve maximum revenue and low denial rate.

MedicalBillersandCoders.com is renowned for providing the best medical billing services, constantly updating itself on industry changes and providing a team of billing specialists to ensure least denials and maximized revenue. We provide the complete suite of medical billing services right from patient verification to claim posting and follow ups. The entire medical billing cycle or just a part of it like Denial management can be outsourced to MBC for reducing denied claims and maximizing profits.



Category : Accounts Receivables / Claims Denials