How to Avoid Claim Denials in your Practice?

If you do not want to be part of this number, prevention is the key to keep your medical billing and coding better to avoid claim denials in practice. Unless you prevent it from the beginning, it will seriously impact your practice.

Undoubtedly, the average denial rate was 11.1% in the third quarter of 2020 which was further increased to 23% with increasing burden of low reimbursement

Obviously, payers would love to delay or reject the payment, and they will do it when you give them an excuse. So, while you lose your revenue, it will eventually hinder your productivity and time lost in claim investigation and resubmission.

But don’t worry because 90% of the denials are preventable with best practices and one can work proactively to prevent such rejections. While putting the proactive process into action can be challenging, simple operational changes can help you save money and time.

Here are six proactive ways to avoid claim denials in practice.

1. Educating and Communicating with the Staff

Similar to any other business, internal and external communication is the key to success, including the healthcare industry. Every member must be on the same page, from the front office team to the medical staff and the back office. In addition, each of them must understand their role for the practice to be successful.

They should all be aware of the process from checking in the patient, documentation, and collecting the payment to ensure no financial loss and improve patient satisfaction.

Educate and communicate with the staff on the elements and services your facility doesn’t offer. It is vital that they know each patient’s insurance plan and what is covered, the co-pays and deductibles, and the proper coding for submitting the bills for the services provided. A part of the communication also includes keeping your team up to date with the certifications and educating them on the latest changes in healthcare.

2. Ensure Insurance Verification before Service

The need for early verification before the service cannot be overstated in the healthcare system for your practice’s financial success. It will prevent claims not only from denials but also write-offs. Whether a patient is a regular or a new one, always verify the insurance. Even a long-time patient can undergo insurance change for switching jobs, sudden job loss, retirement, the beginning of Medicare, switching between insurances, and other factors affecting the coverage.

It is helpful to remember that the same insurance company can offer different coverage, deductibles, and co-pay from year to year. Hence, it is essential that before every visit, the patient’s insurance is checked and work on the services is according to the coding and billing.

3. Knowing Your Payers

Most providers are willing to accept over 20 insurance plans. However, within similar plans, some variations change the allowable and the items that can be reimbursed. Also, every provider has to enrol in the plan before they reimburse.

The process is complex but vital. It is better to have a close relationship with the key payers. Knowing them well will help you understand how the payment works and help you be on the top of the game. They often keep you updated on the evolving rules, pre-authorization, referrals, and other reimbursement features.

4. Proper Documentation

The implementation of ICD-10 now requires you to be more specific with the documentation. No longer are the shot hand notes in the documentation accepted. More than ever, accurate and proper documentation is a must for any service to ensure no claim denial, and you get paid appropriately for the services rendered.

Even a part of the proper documentation requires your staff to get regular training on the healthcare coding and billing changes.

5. Leveraging Technology

While it is essential to invest in Practice Management and/or Electronic Health Records (EHR) system, it is futile to have it unless used across the practice. This is because the technology and the software are expensive, and learning them is time-consuming. However, if it is fully integrated and every staff knows how to use it to its full advantage, crucial information is never lost.

The technology is developed to ensure there is no loss of information in practice, and an integrated system can help review and flag the claims before they are sent to the payers. Immediate notification thus helps in preventing denials and developing a better revenue cycle management.

6. Learning from the Mistakes

One of the critical areas to ensure no repeat mistakes in claim denial is learning from the mistake. There are times when a few steps are missed while coding and filing for the claims in a rush. But with the healthcare industry and its rapid changes in the regulations and policies, these mistakes can be pretty detrimental to the practice. So, keep going through the documents when claims are rejected and find the errors, so they are not repeated to avoid claim denials in practice.

The devil is in the details when it comes to medical billing and coding. 

How to Ensure Cost-Effective & Efficient Denial Management?

Training your staff regularly and updating the technology and software can be time-consuming and costly. Moreover, with the ever-changing rules and regulations in the healthcare system, keeping up-to-date can be another roadblock. In all such scenarios, one of the best and most effective ways to ensure the full proof revenue management cycle is outsourcing medical billing services to an expert company like 24/7 Medical Billing Services.

This outsourcing partner have a dedicated team that handles the claims, processes the denials, and follows up on them until it is paid. In fact, the experts of this outsourced team ensure that your practice becomes profitable and sustainable by identifying the root causes for denials, boosting the revenue cycle team, and reducing the backlog while following the industry’s best practices.

Read more: How To Prevent Claim Denials From Payers?

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