There are many things that healthcare providers need to consider in today’s ever-changing climate. From the challenges that come with obtaining proper Medicare reimbursement to CPT code changes, the world of ENT medical billing services can become an obstacle for many growing practices.
Many medical practices across many different specialties are turning over their books to professional billing services in order to stay ahead. However, because the needs and requirements of each individual practice can vary greatly depending on location, patient demographics, and other unique elements, it is important to hire the best medical billing services that can address those needs and step up to meet those requirements.
A recent study found that on average almost $15,000 per year is spent on investigating, appealing and reworking denied claims. Having a high denial rate means more time and money spent on reworking and resubmitting claims to payers. The good news is that there are actions you can take to help your practice reduce denials.
Inefficiencies in the medical billing process such as claims paid below the contracted rates, or services that are never billed, can impact revenues negatively. The majority of the companies, even with a seamless billing process, are known to experience claims rejection rate of 15% percent on the first pass, or with more complex patient rates, it may climb higher. Claims adjudication can be expensive especially when refilling and resubmitting, with costing going up to $25 per claim or even higher. Hence, optimizing the claims submission process brings in higher benefits with the first-pass payment rate, and thus shortens the A/R billing cycle.
One of the significant mistakes that happen is the claim denials and rejections are mentioned in the same breath – There is a difference:
These are the claims which do not meet the specific data requirements or the basic format necessary are rejected. The rejected claims are not processed because they are not considered to have been “received” by the payer, and thus do not make it into the adjudication system. A rejected claim can be resubmitted when the error (or errors) is corrected appropriately. It’s important to note that beneficiaries of a rejected claim cannot be held liable because the services were never actually billed. However, some rejections are not appealable given if they have been rejected on the first instance of posting a claim.
The denied claims are those which have been received by the adjudication system of the payer, and cannot be resubmitted because the payment determination has already been decided upon. A denied claim can, however, be appealed by the request of the payer to necessitate the proper modifications, additional required documents, etc.
The tips below will help you understand how your practice is performing and help monitor denials so you can at a minimum maintain the industry standard denial rate of 3% to 5%.
- You need to make sure that correct medical provider information has been submitted
- You need to make sure that correct patient information
- You need to make sure that it is an error-free diagnosis or point-of-service code is entered into medical billing software
- You need to make sure that the treatment and diagnosis codes match properly
- Conduct Workflow Analysis which includes the accounts receivable (AR) process, billing/expenses, supply costs, sales prospecting, and closing, denials, utilization review and, staffing.
Fill in the gaps by understanding the underlying reasons for claim denials, remember services not covered, a medical necessity not established, prior authorization not obtained, claims filed incorrectly, supporting documentation missing, timely filing, etc. Investing time into the denial management strategy can minimize the impact on the medical billing practice.
Making an effort to reduce the amount of denied claims will require additional effort as the direct cause can be slightly more difficult to sniff out. Once workflows are assigned to process denied and rejected claims separately, the bottom line of that organization will improve immediately.