5 Ways to Prevent Claim Denials

5 Ways to Prevent Claim Denials

The U.S. Government Accountability Office (GAO) reported that the Department of Health and Human Services (HHS) collected information from insurers in America and found that the aggregate claim denial rate was approximately 20 percent in 2010. That equals one of every five claims filed. Here are ways to prevent claim denials.

1. Accurate and Available Patient Information

Ensure that the patient’s information is accurate and available. This includes correct spelling of the patient’s name, accurate date of birth, and accurate group and identification numbers. Also, some medical billers leave encounter data out of the claim. This will result in an insurance denial.

Many claims processors are detail-oriented and notice omissions and use this as a reason to deny a claim. Some crucial dates to list include date of accident/injury/illness, date of onset of imagesinjury/illness, and date of medical emergency. To avoid this common error, make sure all medical billers fill in all requested and required areas on the claim forms.

Also, have a check system in place for review of the claim before it is submitted. The reviewer must assess for common errors, such as missed fields and inaccurate information.

2. Insurance Coverage

Verify the patient’s insurance information is accurate and up to day. This also involves being sure that he or she is still covered under the benefits provided before rendering services. When there is more than one insurance provider, make sure the primary insurance is listed first and list the other one as secondary.

Also, confirm the eligibility of befits by contacting the patient’s insurance provider to assure that he/she is a part of the policy or a covered dependent. Additionally, check and see if the request services and procedures are covered and that the pre-existing condition clause does not render the patient ineligible.

3. Confirm Referrals and Prior Authorization

To assure payment, confirm referrals from the patient’s primary care physician, and make sure there is an electronic or paper document of this on file before rendering services. Also, verify prior authorization or pre-certification. There should be a designated staff member who reviews the health insurer contract and looks for specific terms, such as pre-determination, pre-authorization, and pre-certification. This is done to ensure that the physician practice complies with the insurer’s verification of benefits for the patient.

One way to obtain a pre-authorization is to have the designated staff member call the medical billing serviceinsurance company directly to verify benefits. Certain insurers will allow the physician’s office personnel to complete the pre-authorization form and either fax it or send it electronically. The health insurer, in most incidences, will request pre-certification for a patient’s surgery or hospital admission.

Therefore, the medical personnel must offer the required patient information, which will explain the medical necessity and support the expected length of stay. The reason for pre-determination is to show determine the patient’s coverage for a specific procedure or service. The insurance company will normally make specify which services require this so that claims are not denied.

4. Documentation

The physician or practitioner should provide complete information and proper documentation. If your office receives referrals, be sure the referring physician issued complete medical records showing medical necessity for the service or procedure.

5. Claim is Not Specific Enough

To reduce denials, the biller should code to the highest level of specificity. A diagnosis should be coded at the absolute highest level for that code, which means the maximum number of code digits is used.

The medical biller should avoid billing with a four-digit code when five digits can be used. Sending the claim in with only four could result in a claim denial. This billing practice facilitates a dialogue between billers and coders. Make sure all billing personnel understand what truncated codes look like so they can identify them before claim submission.

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