Irrespective of who does your billing and coding, whether it be an in-house team of billers and coders or an outsource medical billing company, there will be some denied claims, only that the latter will maintain a standardized denial rate. However, like every problem, there are its causes and something(s) that is its solution.
Fortunately, we’d discuss both of them in this guide. Not only you’d learn the elements responsible for a claim denial, but also how you can prevent it as a healthcare practice. It might be that you are well-aware of these factors and solutions but overlooking them, or you don’t know them at all.
However, this guide would educate you in either case, provided that you follow whatever is in there, it would be credible for sure. Let’s start with the causes of a claim denial, as it will help you devise your own solutions and understand ours better.
Why Do Medical Denials Occur?
There isn’t a single factor responsible for the occurrence of a claim denial, there are multiple, and most of them are often overlooked by the team carrying out the respective duties. The list of these factors is as follows:
- Iterative Claims
- Missing or Incorrect Information
- Adjudicated Claims
- Post Due Date Submission
This happens as a result of poor management and tracking of claims being processed, submitted, and followed up. It could possibly be not an outsourcing company, if they are committing such practices, you need to let them go at once. However, it could fall onto your team of billers and coders.
One possible reason for frequent claims denials could be your team submitting the same claim twice on the same date for the same patient, which provokes a sense of fraudulent activities, compelling the provider to take unfavorable action. We have hinted over the cause well from the start, and doing the opposite comes out as the only solution to this problem.
Missing or Incorrect Information
This could come from the outsourcing company or your team’s end. Both of them could insert incorrect information or leave a box unchecked or unfilled. However, it is still due to the lack of focus or should we say the unwillingness towards work?
It could be anything, what matters is the denied claim in your hand, and that you can only prevent by ensuring the social security number, the name, serials, and codes are utterly accurate. If this is the case, you’d definitely see a decrease in the claims denied in the name of your healthcare practice.
In simple terms, a claim that has already been overseen by the payer, approved or denied, would circulate once again in front of them, and upon cross-checking the data or record, they would spot if they have denied this claim, or have entitled another action against it.
Whatever happens, to be the outcome, it’d surely put an end to the claim you have just submitted, resulting in ultimate denial. If it mimics the already denied claim, you should have followed up on that, and not have submitted the new one, the same goes for the other case, i.e., collected.
Post Due Date Submission
That’s an obvious factor of claim denial. If not all, most insurance providers demand you to submit the claims within a certain timeslot, which, when exceeds, they don’t accept the claims, and deny those submitted.
It is one of the most overlooked factors of claim denials that come from your in-house team of billers and coders the most, and least from the outsource medical billing company.
These were all the causes you may end up with a denied insurance claim. However, to prevent the denials, here is what we think is the list of solutions you could implement within your in-house medical billing and coding team.
How Can You Prevent Claim Denials In Your Practice?
There are, in total, five solutions that we think would be enough for you to find your way back to the track, and maintain the momentum of your revenue cycle management.
- Collect Precise & Adequate Data
- Train Your Team For TQM
- Identify Unfavorable Requirements
- Optimize Your RCM
- Track The Claims
Collect Precise & Adequate Data
By data, we mean to collect the personal and insurance information of your patient with great care. You need to be quite proactive while ordaining the forms, which will be filled by the patients, as those forms must contain everything, you’d need to file an insurance claim, and that too should be collectible.
Also, you need to cross-check the information provided by the patient, and for that, you could repeat the sensitive information to the patient for them to endorse it, or opt for different methods available with the technology.
Train Your Team For TQM
Total Quality Management is the practice of improving the overall operations of any department of an organization, in this case, your healthcare practice, and the department would be the medical billing.
You need to train the team for exceptional management of claims being processed, coded, and submitted — on time, and also those being followed up for their status.
Identify Unfavorable Requirements
In your contract with the insurance provider, you need to identify the requirements that your team is barely fulfilling, not because of their negligence, but because they just can’t on an industrial scale.
Once you have identified them, you need to request the provider to eliminate them, or one possible solution could be opting for a billing or medical credentialing services company, as they would train your team better for those hostile conditions.
Optimize Your RCM
Revenue Cycle Management is what RCM means, and optimizing it deals with improving your process of obtaining patient information, maintaining or storing it, the way you code, compliance, contracts, etc.
If you optimize all of these steps in RCM for the ultimate goal of preventing denials, why would your practice be left behind? There would be no reason, and while improving your RCM, you would also improve the revenue that your practice generates.
Track The Claims
The last solution on this list is tracking the claims being filed by your practice for their statuses. Your in-house team should be prepared enough to mark the time the claim went into processing, when it was submitted, the time of collection or denial, and finally, when should they follow up.
Now that you know the causes of a claim denial as well as the solutions that help you prevent it, you should, at once, dictate them to your team as they are and focus on providing value to both your patients and the insurance provider. It is because, from one perspective, the providers are also your external stakeholders that keep your practice alive and kicky.
I have a Bachelor’s degree in medicine and am presently working at a renowned hospital in California. I used my leisure time to share my expertise with others through my blog. In addition to my work in healthcare, I like reading fiction and enjoy writing posts a lot. I want to use my writing to help the health sector on my blog site. You’ll get exclusive informational content about health & Fitness.