Every-Other-Claim-Is-Denied-How-To-Prevent-Such-Situation-?

A never ending issue for medical practices across the country has been denied healthcare claims. And as we swindle through the healthcare reforms, which is being highly debated, the end result of which won't make a huge difference medicinal services industry. A claim denial management handled manually is a daunting task for the Medical billing and coding personnel's. Also, finding out why a claim is being denied by a payer is a costly and time-consuming venture. According to medical billing experts, it costs around $30 to $35 to manage an average denial.

According to a recent data published by 'RemitData', two of the top five claim denial reasons for 2015-16 were insurance-coverage related. Most of the claims were denied because eligibility had expired or the patient procedures were not covered by the plan in question. Having a solid insurance verification process and denial management process in place, physicians/hospitals can reduce these types of denials in your practice, through efficient best medical billing services and enhancing your overall bottom line.

To keep denials at bay, insurance should be verified before services are provided and should never a burdened task for the medical billing staff to handle. Following are some important points to reduce the chance facing constant claim denials and doing the correct eligibility checks. Create a Verification Checklist

Insurance Verification

The simple trick that lies here is to ask the right questions during insurance verification. It's the duty of the front office staff to enter information collected from the insurance card, phone calls with the insurance company, or electronic eligibility systems.

For Eligibility Verification And Reduce The Denial Your Practice Should Include:

  • Insurance name, phone number, and claims address
  • Insurance ID and group number
  • Name of insured, as it isn't always the patient
  • Relationship of the insured to the patient
  • Effective date of the policy
  • End date for the policy
  • Whether coverage is currently active
  • Whether the insurance covers the procedure, diagnosis, or services to be provided
  • Whether your practice participates with the plan
  • Limitations of the policy, including exclusions or documentation requirements for bills
  • Whether a referral, pre-authorization certificate of medical necessity is required for payment
  • The amount of the patient's copay and deductible

Attaining Accurate Patient Data

It's vital to train the office staff to take extra care when recording data into the patient record. Keep in mind that this information builds the foundation of the claim, and a single billing or coding entry can mean the difference between a clean claim and a denial. Rushing through insurance verification duties and making data errors may cause delays on payments, or the claim could even go completely unpaid, which is bad for any medical practice. So, if your in-house staff is falling short on completing those duties, it's better to contract a specialized medical billing outsourcing companies to handle the denial management queries.

Following Up With the Claims and Patient

If there are any questions or concerns regarding the coverage policy, follow up with the patient about insurance information. Using the various digital platforms communicate with them of eligibility through online systems or the staff can also phone the patient to let them know about co-pays or other issues. Informing patient as early as possible about out-of-pocket expenses increases the chance you'll collect those funds.


Published By - Medical Billers and Coders
Published Date - Jan-17-2018 Back

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