Top 7 Insurance Claim Challenges Affecting Your Practice

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Top 7 Insurance Claim Challenges Affecting Your
Practice

• Significance of Insurance Claim Submission
• Running a successful healthcare practice is much
  more challenging than delivering high-quality
  patient care services. Whether you are running a
  solo practice, a laboratory, a hospital, or a
  dental clinic, there are several things you need
  to get right, including insurance billing.
  Receiving accurate insurance reimbursements is
  considered the backbone of the healthcare revenue
  cycle. Insurance claim submission is challenging
  due to the number of factors affecting the
  process. In this article, we discussed the top 7
  insurance claim challenges affecting your
  practice and also suggested how you can overcome
  them.
• Top 7 Insurance Claim Challenges Affecting Your
  Practice
• Missing and Incorrect Patient Information
• Missing and incorrect patient information is one
  of the most common reasons of claim rejection.
  The front desk team generally doesnt cross-check
  patient demographics and insurance information.
  It could lead to inaccurate data submission
  leading to claim rejection. Clearinghouse rejects
  the claim due to inaccurate/ missing data and
  this claim never reaches the insurance company
  unless its been corrected. You can cross-check
  patient demographics and insurance information
  for its accuracy through a patient portal. Your
  front

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Top 7 Insurance Claim Challenges Affecting Your
Practice
desk team can immediately inform patients in case
of inaccurate information is provided. Accurate
patient and insurance information lead to clean
claim submission resulting in quicker insurance
payments. 2. Improper Coding Small healthcare
practices or solo providers try to manage
everything on their own including medical coding.
They tend to use three to four procedure codes
(CPT) for all their patient visits. Medical
coding is a specialized branch and healthcare
providers are trained for it. Accurate coding
could lead to high denial rates and may
compromise patient care. But the more serious
consequences of up-coding and acts of medical
abuse and fraud could have your practice facing
federal penalties and expensive fines. You need
an experienced and medical specialty-specific
coder. Its also true that such coders are
difficult to find and incur high costs on the
payroll. 3. Non-Covered Services Insurance
companies usually cover most medical services
provided by physicians, hospitals, prescription
drugs, wellness care, and medical
devices. Medicare and other commercial insurance
companies do not cover certain items and
services. Most of the time patients are never
aware that the service they need is no longer
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Top 7 Insurance Claim Challenges Affecting Your
Practice
covered by their insurance until it is time for
payment. You can overcome this insurance claim
challenge by verifying patients coverage at
every visit. In the case of non-covered services
or inactive insurance coverage, you can check if
the patient has additional insurance. If the
patients insurance is not covering planned
services, the provider should notify them that
they may be responsible for the payment, i.e.,
pay out-of-pocket for the service. 4. Missing
Referral or Authorisation In many cases,
patients are required to get a referral from
their primary care physicians before accessing
certain healthcare services. Following the
patients request, the physician may simply write
a script for treatment that references a specific
doctor, such as a specialist. However, some
insurance companies require referrals to be more
formal than a script.  An authorization, also
known as pre-approval or pre-certification, is a
formal request made to the insurance company
before a procedure takes place. Many insurance
companies require authorization for certain
procedures. The absence of such referral or
authorization from patient services can result in
claim denial. Providers office must understand
these requirements and work with patients to get
the necessary referral or authorization before
submitting claims. 5. Missing Documentation
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Top 7 Insurance Claim Challenges Affecting Your
Practice
Every insurance company requires documentation to
pay certain claims. The documentation in the
medical record needs to be complete and accurate
to facilitate an effective continuum of care.
Insurance companies want to know if the patient
has tried cheaper alternatives before approving
surgery. The insurance companies may deny the
claim because the documentation is either not a
definitive diagnosis or does not support
severity. When documentation is accurate and
complete, it works wonders at telling a patients
story and can even improve patient care.
Insurance companies will not hesitate to decline
any claim that lacks proper documentation. To
improve documentation, most experts suggest
establishing provider education at the classroom
level. Provider needs to document clinical
decision-making, rather than just documenting
everything. 6. Claim Rejections and
Denials Researchers from California Nurse
Association found that 22 percent of the claims
submitted were rejected. Denied claim percentage
depends upon every practice, it ranges from 10
percent to 60 percent in some cases. The
highlighting fact of this survey research is 40
percent of the rejected claim is never
resubmitted and 65 percent of denials are never
appealed. Receiving accurate insurance
reimbursements is essential for the financial
sustainability of any practice. Denied and
rejected claims can severely damage your
practices
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Top 7 Insurance Claim Challenges Affecting Your
Practice
day-to-day activities. To manage this insurance
claim challenge, providers need to work with
experienced billers and coders to understand
denial reasons/patterns, find a resolution, and
appeal it in a timely manner. 7. Lack of Patient
Education Patients generally have little
knowledge of medical billing. Some may have no
idea that the service they are trying to access
requires referral or authorization, or that their
insurance coverage has changed for some reason.
The obvious solution is to educate patients and
inform them about financial responsibility. After
paying insurance premiums they are hesitant to
pay patient portion amounts like co-payments,
co-insurance, and unpaid deductibles. With the
patient portion increasing exponentially and more
and more patients accepting High Deductible
Health Plans (HDHP), its always advisable to
educate patients on treatment plans, their
insurance coverage, patient payment portion, and
payment options. Educated patients are more
likely to complete the treatment and are mentally
prepared to make payments at the time of visit
only. Medical Billers and Coders (MBC) is a
leading medical billing company providing
complete revenue cycle management services. While
working with healthcare practices of varied
medical specialties we spotted some billing
challenges and shared 7 such insurance claim
challenges affecting your practice. If you need
any assistance in medical billing and coding for
your practice, email us at info_at_medicalbillersand
coders.com.