Medical offices of any size that ignore denied health claims are essentially relinquishing revenue. Instead of going through the time-consuming process of figuring out why some claims get denied and how to challenge them, they leave a significant amount behind. Around two-thirds of all rejected claims are collectible, about 65% of which are never re-submitted.
The purpose of claims management rejection is to review any outstanding claims, determine the trend of one or more insurance companies, and make corresponding appeals under the service provider’s contract appeal process. The fault management process finds the root cause of the fault and the cause of the rejection. Providers have many avenues to provide charity services, providing to insurance companies should not be one of them.
There are many reasons why a claim is denied, including:
Monitoring and recording all claims and denials in your practice are critical, as they can help you ensure that complaints and appeals get filed on time, identify denial trends, and maintain a detailed overview of the complaint revenue cycle. Each patient encounter ideally should be coded on the date of service and tracked periodically till the resolution is obtained.
Routinely run a detailed report on denied claims of your practice. Although the reasons for rejection usually vary by specialty. This report will help you identify specific claims more easily without reviewing multiple claims. Also, be sure to keep a list of records of your denials, including the type of denials, the receiving date, and the appealing date. If you discover a problem trend in this documentation, please address it immediately to avoid further denials of claims.
Knowing your clinic’s denial rate can help you address areas that are particularly problematic for your revenue cycle. The American Academy of Family Physicians (AAFP) provides the following method to calculate your clinic denial rate: Divide the total amount of claims (in U.S. dollars) rejected by the payer within the period by the total amount in U.S. dollars during that period. If possible, you should also calculate your trends based on the payer, the provider, and the reason for rejection.
Knowledge of complex and changing documentation requirements (ICD10) and accurate data entry is critical for practice staff to mishandle the application process on time. Ensure that you have the right staff to handle the applications and communicate regularly with your team members about policies and procedures that affect denied claims. Emphasize regular training to keep employees informed of new or updated diagnostic and procedural codes, appeal procedures, and individual payment instructions.
Many providers still rely on mailing out paper appeals. These take an inordinate amount of time and most payers only allow you to send 1 or 2 appeals before cutting you off. Even though hold times are long, you should call the payer before sending out appeals. Even before that, use the tools provided on payer websites to see if you can get more information or are able to upload documentation from there.
As a disclaimer to automating your processes, do not rely completely on automatically posting remittances. Many billing systems promote the fact that you can press “one button” and the system will do the posting for you. Well, they will go ahead and post the denials also and never show you what got denied!!! Be very cautious when using your billing software.
Leave it to the experts. Integrity Practice Solutions has 400+ employees who live and breathe claims processing. We enable you to achieve high Claims Denial Reversal, improve cash flow and peace of mind by:
