Getting a denial for wound care claims is upsetting for both the doctor and staff. Often, the doctor sees this in a negative light. If the dollar amount in question is small, he or she may completely disregard it, believing it is “not worth it” to appeal. When repeated problems involving specific codes occur, it becomes cumbersome for the physicians. Instead of looking at a claim denial as a defeat, try to look at it as an educational opportunity. Unless one understands the reason for the denied claim, the doctor or staff will more than likely repeat that error over and over again.
The following are the simple hacks to prevent wound care denials:
Understand the basics:
Billing and coding is the procedure through which insurance companies and the government instruct healthcare providers for payment of services. Coding, with all of its regulations, is how they want to see it?
In the billing and coding world today, it is more and beyond about getting paid. Protecting your center from a recovery audit contractor review means maintaining accurate documentation to support the associated billing and coding.
Know what RAC auditors are looking for:
Wound care is on the hit list of RACs’ as of, and it can be very frustrating when money is taken back from the center. This happens even on legitimate claims when the documentation is reviewed and determined to be incomplete.
With all of the reimbursement cuts over the last few years, wound centers need to bill for all the services they perform. One of the best things about having wound care is, if operated correctly, a wound center should be profitable and able to stand on its own.
Understand the insurance verification and authorization process:
Before a patient presents at the clinic, a staff member should begin the process of insurance verification and authorization. A center receives referrals from many places and, in most cases, insurance information is passed along. When this information is received, it is best to take on Ronald Reagan’s old adage, “trust but verify.” The insurance should be verified prior to the first visit and re-verified on a regular basis. I recommend verifying insurance on a monthly basis.
In the current healthcare landscape, expect a patient’s insurance to change often. The front desk coordinator should not expect patients to volunteer the information. By the time they alert the center of a change, revenue may have already been lost from previously filed claims.
In addition to verification, it is good practice to find out if prior authorization for a visit and/or procedure is required. It is important that whoever is handling authorization knows which treatments patients are receiving. This process is perhaps the most important factor in the financial success of any center.
Avoid the denial in the first place:
Several hospital systems will inform a wound center of denials only if the denial was preventable. However, if a center is not fully aware of all denials, then its staff cannot take corrective actions to avoid future penalties. For example, there may be a process that needs to change in order to avoid more denials. The more revenue knowledge given to the center, the more tools clinicians have to ensure accurate documentation and the financial success of the center.
It is imperative for the centers to stay updated on the current laws and regulations when it comes to billing and coding. A professional billing and coding team begins working with an existing center, and they assess the medical billing and coding by reviewing the documentation. This includes both present and past documentation looking for patterns of denial. Once they understand the reasons for non-payment and issues are identified, the team assists in developing a process to assure a low to no denial rate.
Train your wound center’s staff about the broad knowledge of billing and coding:
As discussed earlier, most physicians and clinicians have little to no knowledge of the coding process. Typically, this is entrusted to their hospital’s health information management department. However, with all the changes going on when claiming reimbursement, it is more important than ever for all clinic staff to have a broad billing and coding knowledge base.
Without a financial understanding, physicians may be offering costly treatments when there may be other effective but less costly treatments available. If you don’t know what or how you are getting paid, you aren’t able to make a decision for change.