“The best defense is a good offense” a precept that has been applied in various fields. You have to be attentive when filing claims to insurance to achieve the max first pass acceptance ratio. Your perception that everything was submitted correctly, still leads to scores of reasons for claims to get denied by the insurance. Lack of specificity of codes being used, modifiers not been applied correctly and many more such reasons which might show less in percentage but would out way the overall charges submitted. The American Medical Association reports that between 1.38 percent and 5.07 percent of claims are denied by insurers. Even the best-performing medical practices experience a denial rate of 5 percent, reveals the Medical Group Management Association.
Source: 2012 National Health Insurer Report Card, American Medical Association. Question: “What percentage of claim lines submitted are denied by the payer for reasons other than a claim edit?” According to the survey, a denial is defined as the allowed amount equal to the billed charge and the payment equals $0.
Failure to work on denials from insurers leads to revenue loss for your medical practice. It’s easy to put blame on someone else; it is business-critical to develop and optimize proven techniques that get claims paid. Let me present you the “Standard Operating Procedures” which would keep your practice on the right track and curb on claims denial.
Why your claim has been denied
The first step in a successful claims resolution approach is to identify not only that a claim has been denied, but also the reason for the denial. It would have been so easy if there had been technical error, simply correct the error and resubmit the corrected claim. On several occasions claims get denied due to provider or facility is out of network, determine if services were provided on an emergency basis and if so, review the carrier policy regarding coverage of emergency care. If your services falls within the policy guidelines then prepare a letter and submit supporting evidence regarding the medical necessity.
Similarly, if the procedure was denied for “medically necessary”; you will need to prepare information to prove that the treatment, service or procedure was appropriate, effective, and necessary for the stability, or restoration of the patient’s health. Before submitting supporting documents find out if other providers are using the same procedure, service or treatment for like medical situation and are they getting paid.
Seek the advice from experts as they would be most up-to-date with policy guidelines and on “How to” get paid on procedures and services.
If it is had been denied as “not a covered procedure”, obtain an interpretation of the specific wording with respect to the denied procedure from the insurance company.
Managing claims denial
The moment the denial is received scores of activity takes off within the practice. Once the denial is identified, which may occur manually or automatically, an action plan to resolve the denial (getting the claim paid instead of rejected) must commence.
Look for ways to better organize and speed up the handling of denial-related information. It would be great to use automation process to route denied claims directly into work list based on adjustment reason code or remarks code instead following the legacy of printing, copying and filling each denied transaction.
Route all coding-related denials directly to first level submitter “your coder(s)”. Let the coders review the denials and take the action on each item from their work list.
Check if the required forms are available, identify the deadline for filling the appeals, etc. See if you have the option for getting the claim reconsidering over phone, if not verify the address and to whose attention the appeal should be sent for reconsideration.
Send a copy of your request for denial reconsideration to the guarantor on the account, too. A patient notified of a denial may be concerned that he or she could become financially responsible. This may spur the patient to contact the insurer directly to discuss the situation. The odds of a denial receiving additional reconsideration improve when both the practice and the patient are communicating to the insurer about it.
Involving patient’s employer
You may want to contact the patient’s employer with claims processing problems. Some insurance carriers are more responsive to their corporate clients, and most large companies have a benefits manager or administrator that should be able to assist in getting difficult claims processed.
Build strong case when researching the claim
To support your rationale for payment, attach necessary documents, such as documentation of the service, relevant medical literature, a record of the original filing of the claim, and copies of sections from the CPT® book or CPT® Assistant that explain the appropriate use of the code in question. Document all dates, times, and who you spoke to. Include all correspondence and dates of submission. Record commitments made by the carrier’s representative and make them accountable.
Claim denial is a core source of frustration for the billing staff, and plays a vital role in dampening your practice cash flow. Make sure to address denials promptly to determine what action is needed and always keep the patient’s best interests top of mind. Most importantly, do not let denials pile up.
About the author
Tejhas Vyass, a technocrat and result oriented with over 11 years of experience in US Healthcare Industry works with iPatientCare users during their inbreeding, involving, enrollment, training, configuration, and go-live assistance. He possesses an in-depth and up-to-date knowledge of the US medical insurance and revenue cycle management for small and medium sized physicians’ offices. An effective communicator with exceptional relationship management skills, iPatientCare users admire him for his knowledge, brilliance, and willingness to help during any and every step of implementation and support.