Best Practices After Claim is Denied by Insurance

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Best Practices After Claim is Denied by Insurance
Insurance Claim Denials Its quite normal for
any healthcare practice to receive claim denials.
When the practice is new or new providers are
added or contracts are revised or new payers are
added then you might receive more claim denials.
Its quite normal to receive claim denials due to
these mentioned reasons, plus insurance companies
keep on changing/updating their reimbursement
policies leading to changed billing and coding
guidelines. Your claim denial percentage must be
under check all the time. You should not receive
more than 15 percent of claim denials at any
stage. In this article, we shared best practices
after your claim is denied by the insurance
company. Consider these best practices as general
guidelines and modify them as per your practice
specialty size and payer mix. Best practices
after claim is denied by insurance Read
EOB/ERA
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Best Practices After Claim is Denied by Insurance
Most healthcare practices just focus on
submitting the claim and forget about reviewing
remittance advice received from insurance
companies. Insurance companies share remittance
advice for every line item called Explanation of
Benefits (EOB) or Electronic Remittance Advice
(ERA). Read every line item carefully and check
if the claim is fully denied or partially
denied. Understand denial Every payer will
give a reason/denial code for every denied line
item. Understand these denial codes, most
insurance companies will also provide a detailed
description of this denial code. Denial
management team Identify the available experts
from the RCM department and leverage their
expertise to put in place solutions and to track
and report developments. It will help to set up
benchmarks, reduce backlogs, and identify root
causes. The denial management team would include
key members from billers, coders, accounts
receivable, admitting/registration, case
management, patient financial services, nursing,
health information management (HIM), information
technology (IT), finance, compliance, and, of
course, the physicians.
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Best Practices After Claim is Denied by Insurance
Act quickly Most important thing in denial
management is to acknowledge that you received a
claim denial and act quickly to resubmit the
corrected claim. Follow a validated process to
get denials corrected, preferably within a week,
a goal that is possible when an established
workflow is in place to track claims as they
enter and leave the system. Most important thing
is, to try to meet deadlines. Failing to follow
deadlines established by insurance company
policies can affect claim filing. Verify patient
information Most of the claims got denied due
to wrong patient information. Patients forget to
update their information with providers resulting
in submitting old patient data and receiving
rejections. Leverage patient portals that update
patient information and take time to verify that
information and the patients insurance
coverage. Identify trends Quantify and
categorize denials by tracking, evaluating, and
recording the trends. Understand importance
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Best Practices After Claim is Denied by Insurance
of data, and emphasize this data and analytics to
help identify and rectify the issues causing
denials in the first place. Identify top denial
code reasons for every insurance company and set
up preventive measures to avoid them. Conduct
regular follow-ups Track every claim so denials
and rejections can be corrected and resubmitted
on a scheduled appeal, preventing revenue
loss. Quality over quantity If you have
limited resources then focus on claim denials
with a maximum dollar amount. Identify the
pattern payer-wise, patient-wise, or denial
code-wise and check if a single resolution works
for all these denials. Keep the process
organized
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Best Practices After Claim is Denied by Insurance
Losing track of denied claims will severely
affect your practices revenue. Climbing denial
rates will also lead to some serious
administrative problems. Keep your denial
management process organized and follow all the
steps from time to time. Make sure that job
responsibilities given to denial management team
members are transferrable so that in absence of
one team member whole process wont come to stand
still. Track progress Monitoring progress will
help differentiate between areas that are doing
well and those that arent while allowing for
analysis and improving system efficiency. This
helps your organization know which areas are
doing well and which need improvement. Conduct
timely internal performance audits. These should
include audits of remittance advice reviews,
write-off adjustments, zero payment claims,
registration, and insurance verification
quality. Collaborate with payers Payers also
benefit from resolving denial issues, so a
payer-provider collaboration can help in
addressing them more efficiently, which will also
help achieve system efficiency more rapidly.
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Best Practices After Claim is Denied by Insurance
Outsource   Finally, consider supplementing
internal medical billing and coding operations
with outsourced services. Through outsourced
services, healthcare practices can quickly gain
access to a team of highly trained and skilled
professionals who dedicate their time to
interacting with insurance companies and
understanding the reasons behind rejections and
denials. Investing in the support of outsourced
services can also allow internal teams more time
to concentrate on other aspects of maintenance
and patient experience. Medical Billers and
Coders (MBC) is a leading medical billing company
providing complete medical billing and coding
services. We can provide your complete assistance
in addressing a claim denied by the insurance
company. We help practices to reduce claim
denials and increase collections by offering
medical specialty-specific billing and coding
services. To know more about our services, email
us at info_at_medicalbillersandcoders.com or call
us 888-357-3226.