Claim denials can be a major source of frustration for physicians and their practice managers, and can have a real impact on cash flow and the financial performance of a practice. If office procedures are good in gathering correct information and submitting clean claims, you can still expect to see at least 5% of denials for claims. So, how can you conquer the issue? Read on.
Set a Goal for Perfection
The goal should be for your practice to have its claims accepted on the first submission. However, this requires taking steps much earlier in the revenue cycle.
To begin the process, identify and record the exact reason for every claim denial. This can be done quickly and easily by using a denial management module that is built into the overall practice management system. A variety of reasons will come up: The payer may insist that the stated diagnosis does not support the medical necessity of the services, or there may be missing paperwork in the documentation for the claim. The claim may be denied if the patient is not a covered beneficiary of the payer to whom the claim was submitted.
The various reasons that emerge should guide your practice to take two actions: 1) Make immediate efforts to correct the errors and reverse the denial, and 2) modify your practice processes to prevent the errors from occurring in the future.
Do Not Ignore Denials
There are several possible responses to a claim denial. For example, once the root cause of the denial is established, try to correct and resubmit the claim. First, find any missing paperwork and add it to the claim. Change inaccurate codes to the right ones, or determine the patient's correct insurer and submit the claim to it.
If the practice cannot fix the reason for the denial, or the payer refuses to accept the correction, it may make sense to drop the matter and write off the charge. A write-off is necessary if the practice cannot locate the documentation to support the claimed service or if it turns out that the service was really part of a bundle that already has been paid separately and never should have been claimed in the first place. Nonetheless, this should be the last resort.
In the event that your practice makes what it believes to be appropriate corrections, but the payer still rejects them, the last option is to appeal the decision. You will need to contact the payer to learn its reasoning on the matter. Then, you must prepare persuasive arguments in support of the claim. As appropriate, gather additional relevant documentation, or obtain more expansive statements of medical necessity from your clinicians. Finally, file the appeal and follow up with the payer every two weeks until the matter is resolved.
Make Needed Changes
Your practice's goal should be to avoid claim denials, so you will need to make systemic changes for the future. For instance, problems with incomplete documentation or improper coding may require retraining staff and clinicians. The people may be fine, but the processes they perform may need to be re-engineered. In that case, make sure your practice is getting all the right patient information before or during registration and you're capturing and entering the correct charge codes in a timely manner.
Last, correct pre-adjudication edits returned by the claims clearinghouse on a daily basis. By following the above objectives, your practice will be well on its way to clean claims. As stated before, it's critical that your practice stay on top of your billing and collections process. Your financial advisor can help you get on track.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
