{"id":14718,"date":"2021-12-15T13:25:55","date_gmt":"2021-12-15T13:25:55","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=14718"},"modified":"2025-10-08T11:41:47","modified_gmt":"2025-10-08T11:41:47","slug":"adopting-proactive-approach-to-reduce-claim-denials","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/adopting-proactive-approach-to-reduce-claim-denials\/","title":{"rendered":"Adopting Proactive Approach to Reduce Claim Denials"},"content":{"rendered":"

Claim denial occurs when a claim is submitted by the healthcare provider and is not accepted by the payer. Most practices face the challenge of high claim denials. You would be surprised to know that the highest performing medical practices have only a 4 percent denial rate (as per the Medical Group Management Association survey report). <\/span><\/p>\n

In other words, such high-performing practices receive almost 96 percent of insurance reimbursements within the first month of claim submission. These practices adopt a proactive approach to managing claim denials, they take all necessary precautionary actions to avoid claim denial. <\/span><\/p>\n

Adopting a proactive approach can help to reduce claim denials for your practice also. In this article, we shared such revenue cycle operations that can avoid claim denials at the source only.\u00a0<\/span><\/p>\n

Adopting a Proactive Approach to Reduce Claim Denials<\/span><\/h2>\n
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Collect\u200c \u200cAccurate\u200c \u200cPatient\u200c \u200cDemographics\u200c \u200cand\u200c \u200cInsurance\u200c \u200cInformation\u200c\u00a0<\/span>\u200c<\/span><\/span><\/h3>\n<\/div>\n<\/div>\n
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Collecting patient demographics and insurance information is the first and most crucial step of revenue cycle management<\/a>. Wrong or missing patient and insurance information will lead to claim denial. Just leaving one required field blank on a claim form can trigger a denial. Incomplete information like wrong plan code or no social security number accounts for 61 percent of initial medical billing denials and 42 percent of denial write-offs.<\/div>\n
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You must collect the latest patient and insurance information to be used while submitting claims. Adopt a proactive approach while collecting patient and insurance information, if possible, collect this information 2-3 days prior to patient visit. A couple of days prior to visit, check for benefits and coverage report, login to provider portal and look for updated information.<\/div>\n
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Verify Insurance Coverage<\/span><\/div>\n
\u00a0<\/div>\n<\/div>\n

Almost 24 percent of total claims are denied due to insurance non-coverage. When a patient provides insurance details, that doesn\u2019t mean, all services will be covered under it. Even if a patient has been coming to your practice for years, people change jobs and insurance plans. For each and every patient, perform comprehensive eligibility and verification to find out benefits and coverage of the health plans. Check that the patient\u2019s coverage hasn\u2019t been terminated, their maximum benefit hasn\u2019t been met, and their plan covers the service you\u2019re providing. <\/span><\/p>\n

Ensure that your front desk staff knows the plans you accept, how to interpret policies, and feels comfortable discussing coverage issues with patients. Eligibility and benefits verification will ensure all visited patients have active insurance coverage otherwise you can charge patients for the non-covered portion.\u00a0<\/span><\/p>\n

Check for Medical Necessity and Authorizations<\/span><\/h3>\n

Authorization and pre-certification issues account for 18 percent of total denials. It takes time to learn which services are considered medically necessary, which require prior authorization, and which require referrals. Note that, just obtaining prior authorization doesn\u2019t guarantee payment. The claim also must be supported by medical necessity, filed within the deadline, and filed by the provider noted in the referral or authorization. <\/span><\/p>\n

To stay within the bounds of medical necessity, only perform a procedure if there\u2019s a clear medical reason. Use notes or attach records to support the services provided. The experienced biller can tell you prior authorizations and medical necessity requirements otherwise call the insurance carrier and check if planned services need authorization. Medical necessity and prior authorizations will ensure that your claim will get paid on time.<\/span><\/p>\n

Ensure Accurate Coding<\/span><\/h3>\n

Whether it\u2019s procedure codes or diagnosis codes, some providers use a specific set of codes in each and every claim. Medical coding is a specialized branch and you need a special set of skills to master this field. Just approximately guessing procedure and diagnosis codes is not going to help you. <\/span><\/p>\n

The best way to reduce denials is by coding to the highest level of specificity. This often means coding up to the fifth digit. If you are using an outdated codebook or your coder or your biller enters the wrong code, your claim could be denied. If your practice depends on a hospital or other facility to provide procedure or diagnosis data, make sure that the chargemaster and diagnosis listing contains the most current version of CPT, HCPCS, and ICD-10 codes. <\/span><\/p>\n

It is a felony to make fraudulent representations to receive payment for healthcare services. This includes upcoding and unbundling. Even \u2018honest mistakes\u2019 can put you at risk. Appoint certified medical coders to ensure compliance to payer-wise coding guidelines<\/a>.\u00a0<\/span><\/p>\n

Constantly Monitor, Analyze, and Audit<\/span><\/h3>\n

If your practice has a denial rate of 5 percent or less, you\u2019re within an acceptable rate. However, a denial rate over 5 percent requires review. To reduce rejection in medical billing, learn from your mistakes. Identify why denials are happening. Take a close look at mid-cycle tasks, including documentation, chargemaster set-up, charge capture, and claim processing. Conduct staff audits to ensure appropriate documentation and coding. <\/span><\/p>\n

If you uncover weak links, develop processes to strengthen your practices. Prioritize the changes that will most impact the bottom line. Your team should be well qualified to read remittance advice. Every payer will provide a remark code for every denied claim. Your team should be able to understand it and take precautionary actions to avoid such denials in the future.<\/span><\/p>\n

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Tackling the causes of claim denials from the front end can help healthcare organizations reduce denials and increase the success rate of claims appeals.<\/h3>\n<\/div>\n<\/div>\n<\/div>\n

The above mentioned are major revenue cycle activities to reduce claim denials. But it\u2019s not sufficient, you need to develop a denial prevention culture within your practice to save your time and money. To create such a denial prevention culture within your practice will require expert billers and coders. As per the size of your practice, it may not be economically viable to recruit full-time billers and coders. <\/span><\/p>\n

In such cases, you can think of taking assistance from medical billing companies like <\/span>Medical Billers and Coders (MBC). <\/b>Our expert medical billing services<\/a> ensure that you will receive more than 85 percent of the submitted claim reimbursement within 30 days of claim submission. <\/span><\/p>\n

We also ensure compliance with constantly changing payer policies and reimbursement guidelines. To learn more about our medical billing and coding services, contact us at info@medicalbillersandcoders.com<\/a>\/ 888-357-3226<\/a><\/span><\/p>\n

FAQs<\/h2>\n\n\n
1. Why are so many of my insurance claims getting denied?<\/strong>

Many claims are denied due to inaccurate patient data, incorrect insurance information, or missing pre-authorization. A proactive approach to verifying this information before the patient visit can significantly reduce denials.<\/p> <\/div>

2. How can I ensure patient insurance information is accurate before submitting claims?<\/strong>

Collect up-to-date patient and insurance information 2-3 days before the visit, and verify benefits and coverage. Always check for any changes in the patient\u2019s insurance plan or coverage before services are rendered.<\/p> <\/div>

3. What role does medical necessity play in claim denials?<\/strong>

Claims are often denied due to lack of medical necessity or missing pre-authorization. Ensure that procedures are medically necessary and properly documented, and verify if prior authorization is needed before performing the service.<\/p> <\/div>

4. How can I avoid incorrect coding that leads to claim denials?<\/strong>

Use the most specific and up-to-date codes for both diagnoses and procedures. Ensure your coders are certified and familiar with payer-specific guidelines to avoid errors like upcoding or unbundling.<\/p> <\/div>

5. How can I reduce claim denials and improve reimbursement rates?<\/strong>

Regularly monitor and audit your claims to identify patterns of denial. Train your staff to understand denial codes, improve documentation, and refine coding practices to reduce errors and improve reimbursement timelines.<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"

Claim denial occurs when a claim is submitted by the healthcare provider and is not accepted by the payer. Most practices face the challenge of high claim denials. You would be surprised to know that the highest performing medical practices have only a 4 percent denial rate (as per the Medical Group Management Association survey […]<\/p>\n","protected":false},"author":2,"featured_media":14719,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[17],"tags":[3016,3017,596,3018,1138,799,3020,3021,3013,3022,2850,2852,3023],"class_list":["post-14718","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-claims-denials","tag-and-icd-10-codes","tag-claim-denial","tag-claim-denials","tag-claim-reimbursement","tag-cpt","tag-hcpcs","tag-medical-billing-denials","tag-medical-group-management-association-survey-report","tag-payer-policies-and-reimbursement-guidelines","tag-payer-wise-coding-guidelines","tag-prior-authorizations","tag-reduce-claim-denials","tag-revenue-cycle-operations"],"yoast_head":"\nAdopting Proactive Approach to Reduce 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