When you submit a claim to any insurance carrier, it will either get paid, fully or partially, or it might get rejected or it might get denied. Most of the time, providers get confused between claim rejection and claim denial. When a claim is rejected, it generally means details mentioned in the claim are either incomplete or inaccurate.
So, you need to provide accurate and/or complete patient and insurance details for a claim to get processed. But when your claims got denied, means the payer has processed your claim and denied the payment.
Medical Billers and Coders (MBC) is a leading revenue cycle company providing complete medical billing and coding services. In this article, we shared some basic tips for reducing denied claim percentages.
Reducing Denied Claim Percentage
Track Every Claim
The easiest way to reduce your claim denial is to account for every submitted claim accurately. Most practices, focus only on submitting claims as quickly as possible and won’t track them. You need to track every single submitted claim, to classify claims as paid, denied, rejected, in process. As per market standards, it’s quite normal to have around 10 percent as denied claims.
It’s normal because you might be billing new payers, new services, or patients might have switched insurances. Make sure that your denial percentage won’t climb more than 10 percent at any time. If you are not tracking the claim, start taking follow up with all payers for claims submitted in the last 9 to 10 months.
Carefully Read ERAs/EOBs
Insurance carriers will convey claim payment status using Electronic Remittance Advice (ERAs) or Explanation of Benefits (EOBs). Carefully read every line item of remittance advice and can categorize claims as paid, unpaid, and denied.
You need a billing expert who understands every denial reason and remark code and reworks and submit the claim with corrected or/and additional information. It will ensure, you are not missing any claims and all claims needed attention are corrected and resubmitted on time.
Find the Most Common Denials
When you start tracking every claim, you will find patterns in a claim denial, whether it would be patient-wise, payer-wise, or procedure-code-wise. After finding the most common reason for your claim denials, well-tested resolutions will help and you can correct claims without much research.
Some of the common denial reasons are patient’s coverage expired, prior authorization missing, diagnosis codes inconsistent with the procedure, timely filling limit expired. Once you realize the most common denial reasons, modify your billing process to avoid such denials in the future.
For example, once you discovered the need for prior authorization for some procedure codes/ patients then update your billing activities so that you will undertake prior authorizations a few days prior patient’s visit.
Appeal Every Denial
Stop leaving revenue on the table, appeal every denial. If unsure, call the insurance rep and check what additional documentation is required. Examine every denial to see if there’s cause to appeal, if so, then move forward. Just review the denial, appeal the denial, keep your denial letter concise and factual.
Many billing software also offer, a scrubbing feature, which will help you to predict claim denial or rejection, before submitting the claim.
Benefits Verification for Every Visit
Doing eligibility and benefits verification for every patient visit is a must for reducing denials. Benefits/insurance coverage report will help you to understand insurance coverage, patient responsibility, or the need for prior authorization.
There is some billing software that provides the feature of checking benefits reports, or you can check it through the provider portal or you can simply call an insurance rep and request them to send you a benefits report. There is a standard script that you can keep as a reference while calling the insurance rep.
Ensuring that all your submitted claims get paid, will ensure a steady flow of revenue for your practice. Above mentioned tips will help you in reducing denied claim percentage and increasing paid claim percentage. If you are struggling to receive accurate reimbursement for delivered services from patients and payers then we can assist you.
Medical Billers and Coders (MBC) is a leading revenue cycle company providing complete medical billing and coding services. We can assist you in reducing the denial percentage and increasing your insurance collections.
To learn more about our billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226.
FAQs
1. What is the difference between a rejected and a denied claim?
A rejected claim is due to incomplete or inaccurate details, while a denied claim means the insurance carrier has processed it and refused payment.
2. How can I reduce the percentage of denied claims in my practice?
Track every claim, carefully read Electronic Remittance Advices (ERAs) and Explanation of Benefits (EOBs), and identify common denial reasons to prevent them in the future.
3. Why is tracking every claim submission important?
Tracking ensures you identify claims that are paid, denied, or rejected and allows you to follow up on unpaid claims, helping to keep your denial rate below 10%.
4. How can I identify the most common reasons for claim denials?
By tracking claims over time, you can spot patterns such as expired coverage, missing prior authorization, or incorrect diagnosis codes, and take steps to address them.
5. What should I do if a claim is denied?
Always appeal a denial, review the reasons carefully, gather any necessary documentation, and submit the appeal to maximize your chances of getting the claim paid.
