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Best Practices After Claim is Denied by Insurance


Article-Best-Practices-After-Claim-is-Denied-by-Insurance

Insurance Claim Denials

It’s quite normal for any healthcare practice to receive claim denials. When the practice is new or new providers are added or contracts are revised or new payers are added then you might receive more claim denials. It’s quite normal to receive claim denials due to these mentioned reasons, plus insurance companies keep on changing/updating their reimbursement policies leading to changed billing and coding guidelines.

Your claim denial percentage must be under check all the time. You should not receive more than 15 percent of claim denials at any stage. In this article, we shared best practices after your claim is denied by the insurance company. Consider these best practices as general guidelines and modify them as per your practice specialty; size and payer mix.

Best practices after claim is denied by insurance

Read EOB/ERA:

Most healthcare practices just focus on submitting the claim and forget about reviewing remittance advice received from insurance companies. Insurance companies share remittance advice for every line item called Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA). Read every line item carefully and check if the claim is fully denied or partially denied.

Understand denial:

Every payer will give a reason/denial code for every denied line item. Understand these denial codes, most insurance companies will also provide a detailed description of this denial code.

Denial management team:

Identify the available experts from the RCM department and leverage their expertise to put in place solutions and to track and report developments. It will help to set up benchmarks, reduce backlogs, and identify root causes. The denial management team would include key members from billers, coders, accounts receivable, admitting/registration, case management, patient financial services, nursing, health information management (HIM), information technology (IT), finance, compliance, and, of course, the physicians.

Act quickly:

Most important thing in denial management is to acknowledge that you received a claim denial and act quickly to resubmit the corrected claim. Follow a validated process to get denials corrected, preferably within a week, a goal that is possible when an established workflow is in place to track claims as they enter and leave the system. Most important thing is, to try to meet deadlines. Failing to follow deadlines established by insurance company policies can affect claim filing.

Verify patient information:

Most of the claims got denied due to wrong patient information. Patients forget to update their information with providers resulting in submitting old patient data and receiving rejections. Leverage patient portals that update patient information and take time to verify that information and the patient’s insurance coverage.

Identify trends:

Quantify and categorize denials by tracking, evaluating, and recording the trends. Understand the importance of data, and emphasize this data and analytics to help identify and rectify the issues causing denials in the first place. Identify top denial code reasons for every insurance company and set up preventive measures to avoid them.

Conduct regular follow-ups:

Track every claim so denials and rejections can be corrected and resubmitted on a scheduled appeal, preventing revenue loss.

Quality over quantity:

If you have limited resources then focus on claim denials with a maximum dollar amount. Identify the pattern payer-wise, patient-wise, or denial code-wise and check if a single resolution works for all these denials.

Keep the process organized:

Losing track of denied claims will severely affect your practice’s revenue. Climbing denial rates will also lead to some serious administrative problems. Keep your denial management process organized and follow all the steps from time to time. Make sure that job responsibilities given to denial management team members are transferrable so that in absence of one team member whole process won’t come to stand still.

Track progress:

Monitoring progress will help differentiate between areas that are doing well and those that aren’t while allowing for analysis and improving system efficiency. This helps your organization know which areas are doing well and which need improvement. Conduct timely internal performance audits. These should include audits of remittance advice reviews, write-off adjustments, zero payment claims, registration, and insurance verification quality.

Collaborate with payers:

Payers also benefit from resolving denial issues, so a payer-provider collaboration can help in addressing them more efficiently, which will also help achieve system efficiency more rapidly.

Outsource:

Finally, consider supplementing internal medical billing and coding operations with outsourced services. Through outsourced services, healthcare practices can quickly gain access to a team of highly trained and skilled professionals who dedicate their time to interacting with insurance companies and understanding the reasons behind rejections and denials. Investing in the support of outsourced services can also allow internal teams more time to concentrate on other aspects of maintenance and patient experience.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We can provide your complete assistance in addressing a claim denied by the insurance company.

We help practices to reduce claim denials and increase collections by offering medical specialty-specific billing and coding services. To know more about our services, email us at: info@medicalbillersandcoders.com or call us: 888-357-3226.

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