29 Sep Preventing Medical Billing Claim Denial
According to the United States Government Accountability Office (GAO), data collected from insurers nationwide showed an aggregate application denial rate of 19 percent in 2010. This was around one in five claims. Quite often, claim denial is avoidable. Before you let money walk out the door, consider these methods of limiting the amount of denied claims in your office.
- Make sure all patient information is accurate and available. This includes correct spelling of the patient’s name, accurate date of birth, and valid group and subscriber numbers.
- Verify insurance coverage. Make sure the insurance benefits are up to date and in effect before rendering services. If possible, contact the insurance company to verify coverage.
- Coordinate benefits to assure you are using the correct primary insurance company. Also confirm the eligibility of these benefits and verify insurance information.
- Contact the insurance provider to make sure the physician or provider is part of the network. During this time, also verify that the requested services will be covered and that the services do not fall under any pre-existing disease or condition clause.
- Use complete, valid, and appropriate CPT and/or HCPCS codes on the claim.
- Make certain the doctor gives adequate documentation to support the services and/or supplies billed.
- Confirm necessary referrals form the patient’s primary care provider, and make sure a document verifying this is on file before services are rendered.
- Check on prior authorization and pre-certifications. Find out if or not they are required, and if so, make sure documentation is on file before rendering services or supplies.
- File all claims in a timely manner and before the insurance carrier’s deadline filing dates.
- Bill the right liability carrier for treatment when handling an auto-related or worker’s compensation claim.
Why Verify Insurance?
There are a number of reasons why medical billing claims get denied. When you do not verify insurance, this costs time and money. Be sure the medical billing professional contacts each insurance provider to verify effective dates, as well as the coverage period.
Also, assess copayments, check deductibles, and look into pre-existing condition exclusions. Each patient’s policy has limits, so to avoid billing errors and denied claims, make sure services are covered under the plan benefits.
Errors in Medical Claims
A recent study estimated that around 35 percent of all medical claims contained errors. These simple inaccuracies will result in billing denials. Train the front office staff to reduce these errors by updating the patient’s chart and checking patient information.
Also, make sure the diagnosis code corresponds with the performed procedure. While simple mistakes lead to denials, the payment can be delayed for up to 45 days.
Implement a Practice Management System
To reduce human errors, many practices have changed over to an automated practice management system. However, human input into the system often results in errors. Don’t blame the system for all errors.
Make sure personnel are adequately trained on the new practice management system. This type of system allows the staff to automate charges, manage practice tasks, and complete office tasks.
Preventing Coding Errors
Unbundling of codes is when the diagnosis code is not entered into the highest level. These cause problems with claim denials, so coding to the highest level of specificity is important. If all possible, use the fifth digit of ICD-10 for the most specific diagnosis.
Use the practice management system scrubber, which signals when there is an under-coded diagnosis on the claim. Make sure all medical billers and coders understand what a truncated code is so they can fix these before the claim is submitted.