Did you know that claim denials can hamper on revenue payments in healthcare specialties? If medical billing outsourcing companies are obscure about the claim denials, then it would lead to tremendous loss.

These specialty denials can have many reasons and few can be very prominent in holding the revenue from entering to healthcare professionals pockets.

Claim Denials in specialty clinics

  • Uncovered procedure
  • Untimely and Repeated Claims
  • Ambulance Based Denials
  • Coding Errors
  1. Uncovered Procedures:

  • The major problem is that some insurance companies does not cover certain specialty procedures.
  • There might be a service in specialty clinics that insurance companies doesn’t include in the coverage.
  • So, prior to providing the service, specialty clinics must verify if the insurance companies provide such coverage.
  • If the insurance company’s plan doesn’t cover certain procedures, the specialty practitioner and the medical billing outsourcing companies must be alerted to avoid bad relationship between healthcare professionals, patients as well as insurance companies.
  1. Untimely and Repeated Claims:

  • Duplicate claims are another reason for claim denials from insurance payers.
  • Medical billing outsourcing companies should train the staff and take appropriate steps instead of concentrating on resubmitting a claim.
  • Another targeted problem is that Medicare healthcare professionals delay in submitting specialty claims which has to be submitted within required window of time.
  • Such situation occurs when healthcare specialty clinics doesn’t pay attention towards smaller claims while concentrating on the larger ones.
  • However, if the claim is held too long, then it will be denied. The eligibility varies from insurance to insurance as well as policy to policy.
  1. Ambulance Based Denials:

  • There’s a possibility for ambulance based denials to happen when the insurance deemed ambulance service is not required for the patient.
  • In order to prevent this situation, ambulance crew members are dedicated and trained for proper documentation.
  • The below list is the key to prepare patient care reports (PCR).
  • A PCR should provide necessary details on patient’s health condition and narrate the procedures of interventions and how they were performed.
  • It should elaborate on response of patient to the treatment or diagnosis.
  • PCR should include the details of patient information and assistance with stretcher transfer.
  • Another important information includes the method used to transfer the stretcher along with the reason for choosing particular method and also the patient care for themselves.
  • PCR’s should be crisp and neat. It should not contain unnecessary words and should be complete and not bloated.
  • The report should also not contain meaningless phrases and also large elaborated sentences that makes the report complicated.
  1. Coding Errors:

  • Coding errors are the another type of denial issues that can directly effect the medical billing process and healthcare practice.
  • Medical billing outsourcing companies should be aware of codes those are standardized identifiers of procedures as explained in medical billing and coding guidelines.
  • Three major types of procedures are CPT, HCPCS and ICD coding.
  • CPT (Current Procedural Terminology) are prominently used procedures that identifies procedures performed in medical facilities.
  • HCPCS (Healthcare Common Procedure Coding System) is the another procedural code that fills the gaps between CPT system.
  • ICD ( International Classifications of Diseases) are the codes used for identifying diagnosis.
  • Medical billing outsourcing companies will need to send these codes accurately as it makes it possible for insurance companies to process the claims without any difficulty.
  • Medical coders in medical billing outsourcing companies must be up to date on the codes used for diagnosis and medical coding process as it prevents from causing major coding issues.
  • American Medical Association actually provides learning resources for how to use and interpret the codes.
  • Most of the coding problems are revealed when Explanation of Benefits (EOB).
  • If healthcare professionals discover procedures those were improperly coded, medical billing outsourcing companies should correct the errors and resolve issues quickly and effectively.

Five steps to Lower Denial Rate in Medical billing outsourcing companies:

  1. Know current denial rate
  2. Identify reasons for denials
  3. Certified team
  4. Multi-disciplinary denial team
  5. Staff Education

1.Know Current Denial Rate:

  • Medical billing outsourcing companies has to calculate current denial rates accordingly by adding the total amount of denied claims by insurance companies within given period.
  • Calculate denial rate according to insurance companies by mentioning reason for denial, healthcare providers and the location.

2.Identify Reasons for Denials:

  • Reasons for denials actually vary according to specialty and practice. Compile claim adjustment reason codes.
  • Map the codes to more actionable descriptors to dig the data and identify the root cause of the problem.
  • Try to categorize claim denials according to common reasons:
  1. When files are not submitted within timely filing guidelines.
  2. Due to demographic errors
  3. Duplicate claims
  4. Expired patient eligibility
  5. Incorrect modifiers
  6. Invalid procedure and diagnosis code
  7. Lack of medical necessity
  8. No proper authorization
  9. No supporting documentation
  10. Additional required information by payers
  11. Uncovered services
  12. Insurance wrongly billed.

3.Certified Team:

  • Certified medical billing outsourcing companies with team to track the denials and improve error free claims.
  • The certified team should clarify with code combinations, claim rejections and more.
  • Medical billing outsourcing companies can validate codes chosen by EHR.
  • Team should find the missing charges according to documentation.

4.Multi-disciplinary Denial Team:

  • Create a team which could put all the effort in denial management that includes practice manager, medical biller and coder, healthcare professionals willing to serve.
  • The team goals should be collect data denials, verify if they can extract the data from practice management system.
  • Review data to identify trends and practice the use for route of denied claims directly to specialty work list.

5.Staff Education:

  • Educate staff to practice accurate data entry.
  • Educate them on policy and procedures of insurance companies.
  • Medical billing outsourcing companies must educate staff on documentation requirements for codes.
  • Educate to fill out the forms properly and the time of service.

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