Is Denial Management a Major Problem?

Did you know that Claim Denials and Claim Rejections are often used interchangeably? How do you think Healthcare Billing Companies manage their claim denials and rejections during lockdown?

Healthcare Billing Companies check for errors while submitting claims to the insurance companies. Yet they meet denials those can at times be a huge loss for the provider and the company.

Sometimes the submitted claims are rejected and denied affecting the reimbursements. Claim denials and rejections are most commonly misunderstood in the medical billing industry. It can create very costly errors and have a negative impact on entire Revenue Cycle Management system.

Difference between Claim Denials and Claim Rejections:

  1. Claim Denials:

  • The submitted claims are received and processed by the insurance companies but they are marked as denied claims.
  • These claims most frequently contain errors in pre-authorization or lack of pre-authorization details that was identified after processing the claim.
  • Some denials include, loss of information, non-covered services, inaccurate details of patient and services which the insurance companies’ policy does not cover.
  • Denied claims can’t be resubmitted, it needs a research in order to determine why the claim was denied, so it can be appealed or reconsidered.
  • If the claim is resubmitted without any reconsideration or an appeal, it will be mostly denied as a duplicate costing more time and revenue loss.
  • Healthcare Billing Companies takes effort to correct the errors and appeal the claim to the insurance company for processing.
  • This can consume time and also be costly lot of resources, to get the exact reason for the claim denials.
  • Time is a major factor while submitting the denied claims. Every insurance company has certain time limit for sending a corrected claim.
  • If the healthcare billing company fails to meet the timeline, the claim will be denied again for the timely filing.
  • This can result in unpaid claim which becomes provider liability.
  1. Rejected Claims:

  • The Claims that doesn’t meet the billing guidelines of the clearing House, repeatedly falls into claim rejections.
  • The submitted claim usually contains errors those were found before processing or accepted by the insurance company. This is termed as “Claim Rejections”.
  • Rejected claims can typically be the result of a coding error, misunderstood procedure, inaccurate ICD codes and termed patient policy.
  • These claim rejections can’t be processed by the insurance companies as they would not have received or entered in their computer systems. So, claims those are not received bounces back.
  • Healthcare Billing Companies resubmit once the errors are checked and corrected. Those errors can be patient’s insurance ID number. Such errors are easy to be corrected and submitted as soon as possible.
  • Accurate medical documentation is a crucial factor of healthcare billing companies in the industry.
  • Healthcare providers utilize these detailed medical records for reimbursement when the claim is in trouble.
  • Even if the claim doesn’t reach the insurance companies, the time to file the claim is very important.
  • The rejected claims should be filed again within the payer’s timeline or would result in revenue loss.

Slow down your denials for the submitted claims by following the below.

9 easy tips to reduce Claim Denials and Rejections:

  1. Use Automated Solutions:

  • Human errors can be really troublesome. The more we can remove human errors, the fewer denials we will deal with.
  • EHR solutions with specialized software that can self-code accurately without any flaws, increases reimbursement levels.
  • If these claims are properly processed at the first attempt, revenue growth can be witnessed.
  1. Check Patient Information:

  • As mentioned, in many cases, the common cause for denied claims like inaccurate information, errors in pre-authorization report are simple to fix.
  • Use a patient portal that updates their information. Even one error in a claim can lead to denial.
  • Take time to verify and check Patient information to reduce instances of denied claims.
  • Keep the billing team updated about the policies and educate staff to improve patient data quality.
  • A call prior to patient visit can be informative with all the required details on patient insurance policy.
  1. Learn from Previous Rejections:

  • If proper data has not been established, it can be cause for claim rejection.
  • EHR offers insurance companies list which is applicable on all insurance types and payer IDs as well as other options too.
  • Well-Organized, this process will reduce the rejection cases in the future and increase revenue flow.
  • Tracking and analyzing the trends in the payer’s rejections and denials are also important.
  • This helps to differentiate denials and rejections which makes it easy to learn where the problem occurred and fix it immediately if they are common.
  1. Meeting Deadline:

  • Deadlines are part of system and it’s important for healthcare billing companies to follow the deadlines according to insurance companies’ policy.
  • If not followed, they might affect the claim filing as well.
  • Healthcare Billing Companies must insist their team to file the claim before their timely filing limits or deadlines.
  • This ensures if submitted claims are processed with no delay and also fits with proper CPT and HCPCS codes if possible and necessary.
  1. Medical Billing and Coding Experts:

  • Optimizing claim management will be brilliant to begin with experts and well trained medical billing and coding team.
  • It can help resolve denial and rejection problems quickly by also decreasing the chance of causing errors.
  • If claims denials and rejections are low, healthcare providers’ revenue will be at no risk and in fact might result in revenue profits.
  • Professional medical billing and coding services ensure and keep your revenue cycle moving successfully.
  1. Familiarize with Clearing House:

  • Clearing House is an essential partner in the claim filing process.
  • From assisting you with insurance companies to explaining the cause for rejections in detail, working with clearing House becomes constant.
  • Maintain a genuine relationship with the clearing House and build a strong contact that will nurture and improve the processes and benefit both the groups.
  1. Understand Claim Format:

  • Many healthcare billing companies using EHR solutions send their claim or submit them through a standardized format.
  • For a denied claim, learning and understanding the claim format will make it easier to rectify the problems and errors.
  • In many healthcare billing companies and practices, the claims are submitted in ANSI837 and understanding on this allows applying ANSI loop and segmenting references which is more efficient than sifting through HCFA1500.
  1. Regular Follow-up on Denials:

  • The submitted claims have to be followed up on a regular basis or else those can get misplaced and sidelined.
  • Keep a track on every claim and follow them, the denials and rejections can be corrected and resubmitted on a scheduled appeal.
  • When a claim is denied and rejected, it’s easy to find the mistake and realize where the problem arises.
  • Revenue growth can be experienced as the claims won’t be missed and revenue loss won’t occur.
  1. Outsourcing as a best option:

  • It can be evident and challenging to meet the denials with the trained staff when compared to medical billing and coding experts.
  • It’s often most cost effective to outsource the medical billing and coding services to healthcare billing companies and rely on services of claim denials experts.
  • Healthcare billing companies will maintain perfect denial management services with professionals who dedicate to learn to interact with insurance companies and understand the reason behind the rejections and denials.
  • Outsourcing provides high level of customer satisfaction and takes the responsibility. As a result, healthcare professionals will have more time to concentrate on other aspects of maintenance and better patient care.

Bonus Tip of 2021: Updated Medical Billing Legislation:

A great way to stay to stay ahead of claim denials and rejections is to study and understand the latest legislation put forward by the federal and state authorities. One such legislation changing the medical billing scenario in 2021 is the No Surprises Act. Here are some things to note:

  • All health emergencies now come under the in-network billing rates, guarding the patients from the exorbitant bills during a crisis.
  • The out-of-network providers should inform the patients beforehand about an estimated break up of medical charges.
  • Any such explanation of billed charges requires a document of lucid text for the better understanding of the patient and concerned parties.
  • If the patient is an in-network facility under the care of out-of-network providers, they cannot be charged out-of-network rates for any ancillary care. This is particularly important since the patient does not choose their ancillary care provider.
  • The law takes a significant step towards balanced billing, banning it altogether for any emergencies.
  • Any deductibles or co-payments, which are borne by the patients, cannot be greater than the payer network charges if an in-network provider treats a patient.
  • For out-of-network providers, the high cost-sharing option has been banned by the law, both for emergencies and non-emergencies.

2022 Update: Price Transparency and NSA

  • The No Surprises Act came into full effect from January 1, 2022. The new regulation is going to drastically change the billing procedure for emergency services, especially which concerns out-of-network providers.
  • Balanced billing is completely banned barring a few exceptions in a few sectors. Medical billing professionals should pay heed to the evolving legislations as any undue case of balance billing is going to bring the healthcare organization unnecessary lawsuits.
  • Taking care of the patient experience is also highly crucial when attempting to implement the law. Patients need transparency in their healthcare services. The No Surprises Act along with the updated Price Transparency Rule is going to provide them an enhanced experience.
  • With the price transparency rule in place, the hospitals need to upload machine-readable files on their public website so that patients can get a more consumer-friendly experience when they walk in to their clinics.
  • Hospitals without the full list of service pricing on their website will be penalized harshly according to the new federal rules. So make sure you are updated on your website.
  • Covid-19 protocols and exemptions regarding Covid-19 billing are also undergoing several changes with the onset of 2022. Different states have been implementing distinct rules on how to bill specifically for Covid-19 medical services.
  • Healthcare billing professionals should definitely keep in mind what the updated rule is in a particular state where the health system is located. Any use of deleted or edited codes will lead to denials and rejection from both Government and private insurance companies.
  • You can install an artificial intelligence tool for your organization to simplify the coding practices for your in-house coding and billing teams. AI and machine learning based systems have in-built features to modify the regular workflow according to the updated regulations and laws of the state.
  • Make sure you train your team with professional learning support to familiarize them with the new software tool to make the most out of your system.

Hope you are satisfied with the information provided about the denial management. If you want to suggest or add anything, please comment below. For more queries and information on healthcare, please subscribe to our blog.