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
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.
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.
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.
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:
Know current denial rate
Identify reasons for denials
Certified team
Multi-disciplinary denial team
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:
When files are not submitted within timely filing guidelines.
Due to demographic errors
Duplicate claims
Expired patient eligibility
Incorrect modifiers
Invalid procedure and diagnosis code
Lack of medical necessity
No proper authorization
No supporting documentation
Additional required information by payers
Uncovered services
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.
Hope you have got the information on Specialty Denial management. For more suggestions, please
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