How to Prevent Claim Denials from Payers?

Do you know that the payers reject up to 10% of all the claims submitted in healthcare practice? However, approximately 90% of the claims that are denied are preventable. The rules and regulations for the claim submission can also vary based on the payer and the patient conditions, and the services offered. But even the most meticulous medical billers experience claim denials.

Is denial management a significant issue?

Once you are aware of the most common denial reasons, you can certainly avoid them and reduce the number of claim denials. Here are the common ways by which you can prevent the claim denials:

  1. Always verify the eligibility and the insurance

Around 24% of the denials happen because of ineligibility. Just like people change their jobs, people change their insurance plans as well. So it is always important to check the coverage of the patient before rendering any service. Also, check- is their coverage still active, do they have the benefits left in their coverage, or do their plans cover your medical services?

You also have to ensure that your medical billing team employees are aware of what plans you accept and how to interpret the insurance policies. They must be updated about the policy and the regulation changes to be comfortable discussing any coverage issues with the existing patients.

2. Collect complete and accurate patient information

If you leave one blank field on the claims form, it can result in a denial. Incomplete patient information, incorrect plan code, missing social security number, etc., account for 61% of the medical bill denials. Of these denials, around 42% of the denials are complete write-offs.

Usually, the most common data missed on the medical billing claims form include the accident date and the medical emergency date, the date of onset for a disease. So it is always wise to double-check:

  • Patient name
  • Date of birth
  • Insurance payer
  • Policy number and other details

3. Always verify the authorizations and the referrals along with the medical documentation

18% of the denials happen because of issues related to pre-certifications and authorizations. While you might take a while to learn about which accounts for medical necessity services and which require prior authorizations and referrals. It is also true that prior authorization doesn’t always guarantee reimbursements. The claims must also have the medical necessity documentation filed within the given deadlines and have the note of referral or authorization. To ensure that you are within the boundaries of the medical necessity, only perform a procedure when there is a medical reason. Don’t forget to add proper supporting documentation for the same.

4. Be updated about pandemic related billing changes

Due to the recent pandemic of Covid-19, there have been many changes in the reimbursable services, which are causing trouble with the providers. This is especially true for telephonic health services. Additionally, CPT code 99072 that became effective from September 2020 was created to cover the costs of pandemic safety measures, including PPE. However, most of the commercial payers have not implemented this code. It is good to put the claims related to this code on hold. You can send them timely for submission to check whether the payers are ready to receive them.

5. Timely submission of claims

Each payer has a different deadline for the claims submission. Editing any claims can cause delays, and they also often push the submission beyond the given deadline. So if you miss a deadline, the claim is usually denied. Create processes to ensure that all the payer’s deadlines are met. You can include a workflow to alert the employees before the date of claim submission.

6. Ensure clean claims with the latest technology

Have your practice management system built-in alerts to ensure all the necessary data are collected at all meet-ups with the patients. While it might sound like a cumbersome process to collect all data accurately, most of these processes can be automated with the latest technology. Many software can review the claims before submission and flag the ones that have missing information. These tech tools can also ensure proper documentation and simply the process of claims submission.

Bonus tip of 2021: Updated Medical Billing Legislation

It is essential to know about the latest legislation updated by the state and federal authorities. One such latest update for the medical billing scenario in 2021 is the No Surprises Act. As per the 24/7 Medical Billing Services experts, there are certain things to be noted in this act that includes:

  • All kinds of health emergencies are included in the in-network billing rates. This is to guard the patients against high bills in the crisis hours.
  • The out-of-network providers must inform the patients about the medical charge estimates with a proper break up beforehand.
  • Any explanation of the billed charges requires proper documentation that the patients and the concerned parties understand.
  • The law encourages balanced medical billing even during emergencies.

Get in touch with our experienced medical billers to discuss more the reasons and ways to avoid medical billing denials.

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