How to Reduce Claim Denials

Consistent cash flow is essential to the health of any business. This holds true for medical practices, as well. Maintaining an adequate level of revenue while minimizing the number of claim denials can be a struggle. Unfortunately, claim disputes have a number of associated costs beyond the denied payment. Estimates show that the average medical practice could loose between $30,000 and $80,000 yearly in denied claims and the staffing expense associated with resolving them.

Appealing denied claims can be a huge time drain on your staff. In some cases, the process is purposefully designed to discourage the provider. It is for this reason that some 50 to 65 percent of denied claims are never disputed. Bottom line and staffing costs can be exacerbated by deteriorating patient relations. When a patient is receiving bills months after service, they are likely to believe the medical practice is mishandling the billing. Ignore the issue and the same denials are likely to repeat. Staff training is a great way to begin addressing the issue of denied claims, but first, try to understand why claims are being denied to begin with. 


Why Are Your Claims Denied?


Denial rates vary greatly from practice to practice and between specialties, but most claims are denied for a handful of reason:

Lack of Specificity – ICD-10 added thousands of diagnosis and procedure codes. Providers must now use the most specific code available to them for each case. Failure to so can lead to claim denial.

Late Fillings – The average medical practice has contracts with 13 payers. Each of these payers has different claim filing deadlines. If a practice files claims weekly it may miss a deadline between filings.

Information Errors – A claim denials can be prompted by a missing subscriber number, incorrect incident date and incorrect patient demographic data.

Coverage Issues – Failure to verify coverage is more common that it should be. Sometimes a patient’s insurance coverage may have changed since their last visit, or their policy may include restrictions on some services. 


Reduce Claim Denials With Staff Training


According to the Advisory Board, 9 out of 10 denials are preventable. The key is to find and correct the root causes of the denials. One root cause of claim denials in almost any medical practice will be human error. A well trained staff can produce clean insurance claims that meet with minimal denials.

Clean claims start with the physician’s input. The doctor’s documentation must reflect the service provided and all of the information necessary to bill that service. Coders review the doctor’s notes and code the claim to the highest level of specificity available. The billers should transfer the data to the claim and review and analyze the claim before submitting it.

When a claim is denied, each team member also plays a specific role. Demographic errors can be corrected by the billers or front desk staff. If a medical necessity issue arises, the physician will need to get involved. Appealing a claim may not require every staff member’s input, but everyone should be aware of who will handle each denied claim most efficiently.




Call Today: 614.706.5206

Popular posts from this blog

IMPORTANT UPDATE: Ohio Medicaid is upgrading its provider enrollment system

Effective August 1, 2022, ODM will not be accepting new provider enrollment applications or continue any in-progress enrollment applications through the MITS Provider Enrollment System. Details on the process for enrollment of new OhioRISE providers from August 1 to October 2022 will be communicated prior to August 1st. Effective October 1, 2022, all provider enrollment applications must be submitted using Ohio Medicaid’s new Provider Network Management (PNM) portal. After its implementation, the PNM portal will be the single point for providers to complete provider enrollment, centralized credentialing, and provider self-service. Provider Network Management Portal and Centralized Credentialing Beginning on October 1, 2022 the Provider Network Management (PNM) portal will accept Medicaid provider enrollments and carry out centralized credentialing functions. This transition will reduce administrative burden for providers and enable providers to focus on the more meaningful and importan...
Read more

CO Supreme Court: Hospital Cannot Enforce $229K Surprise Bill

The surprise bill stemmed from the hospital’s chargemaster rate, but the hospital did not provide this information to the patient before her surgery. The Colorado Supreme Court has ruled that a woman is not liable for her $229,000 surprise bill from a Centura Health hospital, as the hospital did not disclose the amount to her before the procedure. Lisa Melody French received spinal surgery at St. Anthony North Hospital in Westminster, Colorado, in 2014. The hospital initially estimated that the surgery would cost $57,601, with French responsible for paying $1,337 out-of-pocket. But the cost increased to $229,112 following the surgery. According to the court document, the new price tag reflected Centura’s full chargemaster rates for the surgery. Additionally, Centura determined that it had misread French’s insurance card and she was an out-of-network patient. French was left with the nearly $230,000 bill after her insurance paid $73,597 of the new charge, which was over $300,000. Fren...
Read more

Governor DeWine Announces Local Government Payments from National Opioid Settlement Begin

Image
    Ohio Governor Mike DeWine announced Friday that the first payments of funds to local governments from the OneOhio settlement with national opioid distributors have been made electronically. Local governments will determine how to use the payments, totaling more than $8.6 million, to best combat the opioid epidemic in their own communities. Following these initial payments, governments will continue receiving payments from the settlement over the next 18 years. In 2017, as Ohio Attorney General, Governor DeWine was one of the first in the nation to sue opioid makers and drug distributors for their role in flooding the market with massive amounts of highly addictive opioids. A complete list of payments made to eligible and participating political subdivisions may be found at https://nationalopioidsettlement.com/states/ohio/ . The list also indicates if the payment was made directly to the entity or, if less than $500, was redirected to the county. Questions about payments c...
Read more