5 Methods of Managing Claim Denials

5 Methods of Managing Claim Denials

It is crucial for a medical practice to manage claims to prevent denials. Many healthcare organizations are unaware of methods to improve the claims submission process and prevent claim denials. When claims are not resubmitted or appeals for review, the physician is basically working for free. To improve cash flow and prevent loss of revenue, consider these five methods of managing claim denials.

1. Bill the Right Liability Carrier

If the treatment is for an auto-related accident or workers compensation claim, make sure that you bill that carrier instead of the regular health insurance provider.

2. ICD-9, ICD-10, CPT, and HCPCS Codes

The medical billers have to use accurate and valid CPT and/or HCPCS codes when filing the insurance claim. Personnel in the billing department are responsible for entering the right ICD-9, ICD-10, CPT and/or HCPCS codes with correct fees from the practice’s super bill. The physicians billing servicebilling manager should review each claim prior to submission to make sure all forms are filled in correctly.

The use of a sophisticated billing software program will help to flag missing data to prompt billing staff when the field is missing data. If the health insurers regularly challenge billers on certain submission issues, the billing manager should make weekly phone calls to those particular insurers to discuss the outstanding charges. One of the most important things for the billing manager to do is build a rapport with the health insurer representatives, as this will assist in resolving denied claims and increase practice revenue.

The billing staff is responsible for accurately entering the ICD-9-CM and CPT codes and fees as they appear on the practice’s super bill. The practice staff reviews each claim before submission to ensure that they have completed all of the form’s required fields. They might also use a medical billing software program that is designed to flag or prompt practice staff when a required field is missing or the data entered is invalid to avoid a denial of claim.

If health insurers regularly challenge practice staff on claims submission issues, the practice staff sometimes schedules weekly phone calls with those health insurers to discuss any outstanding charges. Building a rapport with the health insurer representatives can assist in resolving future issues.

3. Meet Deadlines

The medical biller has to file claims in a timely manner before the insurance carrier’s filing deadline. Some companies only allow a short amount of time for claims to be filed. Timely filing denials are one of the most frustrating things for a physician’s office. Every payer operates on its own schedule, so it is easy to miss the timing window if the biller does not stay on top of this.

One way to prevent missing deadlines is to have medical billers keep a list of general payer deadlines on their desk. If possible, have a designated person track and document each payer’s receipt of submitted claims.

Occasionally, claims are denied for timely filing even though they were sent in a timely manner but not received by the insurance carrier within the window. The billing manager should hold payers accountable for timely receipt of the transactions.

4. Claim Review  

The billing manager should perform random claim reviews at least once each month or every two to three months. Also, a coding specialist should review the claims each day to ensure that the submitted claims are accurate and based on medical record information. The reason for the claim review is to assess the appropriateness of the coding, billing, and medical documentation and to evaluate the practice’s compliance with standard federal regulations.medical billing service

To complete a claim review, the billing manager should randomly pull five to ten medical records. If there is more than one physician in the practice, samples should be reviewed from each physician’s patients. Also, the review should consider payer status and codes that are frequently denied. After the review, the billing manager should develop a follow-up plan of action to correct and prevent future errors.

The action plan should involve providing physician education, submitting commonly denied claims with office notes and explanation, and seeking advice from a coding specialist for resolving errors. After these actions are taken, the staff must generate a claim and transmit it to the health insurer, according to proper submission requirements or through a clearinghouse, billing service, or application service provider.

5. Claim is Illegible

While most payers are now accepting electronic claims, a few of them may be still requiring manual submissions. Do not focus solely on the electronic claims and give paper claims equal attention. It is common for manual claims to be illegible, which makes them problematic for the payer who scans them into their system upon receipt. The billing manager should have all billing personnel review claims for readability before submission to the payer.

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