To ensure the smooth functioning of operations in healthcare, there must be no loopholes or hurdles detected in the revenue cycle of the organization. The major hurdle for every healthcare organization or physician is claim denials from insurance companies. These are the claims that have been received, processed, adjudicated by the payer who is generally an insurance agency and has been deemed as unpayable.
Claims which are denied cannot be resubmitted without finding the cause of denial. Payers sent their reasons or conditions upon which denial was declared so that billing respondents can send reconsideration requests by analyzing and resolving those reasons.
Though these denied claims can be sent back again after rectifications but the whole process of converting a denied claim into a claim without issues or as per suggestions takes a lot of time and effort.
Therefore, billing agencies to make sure to send clean claims in the first attempt to avoid such a cumbersome process and it is observed that the following are the main reasons for claim denials, and you can perform denial analysis in medical billing for higher reimbursement.
Reasons for claim denials
Incomplete or improper coding
Lack of full and accurate code or bad and old coding are the reasons most claims get denied. Hence you should be aware of the latest changes in coding.
Claim form errors/ Patient information error
These simple errors like missing information of the patient, treatment given, or even nominal form errors could be the cause of denied claims. Especially in emergencies, this information can take you down in a panicked moment and cause an issue.
Claim submission after the deadline
Due to any internal reason, if claims are not submitted or filled within the prescribed deadline of the insurer, then these insurance agencies stand in full right to deny claims.
Healthcare providers sometimes ignore this important aspect of getting a particular service or treatment authorized by the insurer to avoid any such circumstances in the future.
Lack of proper documentation
Insurer companies have their own set of conditions and regulations and to comply with them, one basic yet important step is to provide all relevant documentation about the treatment given and service provided.
Because of the above-mentioned reasons claims submitted by providers get denied by payers and therefore denial analysis becomes an area of vital attention.
Denial analysis can help providers and billing agencies to track where are the shortcomings in the claim submission process and by tracking and monitoring those, you can improve the overall claim denial process to avoid such problems in the future.
Steps to overcome claim denials
These steps can help overcome claim denials and can ensure higher reimbursements
Giving appropriate training to your billing staff and staff that is responsible for handling claims can reduce the chances of errors observed in claim forms and also verify patient information.
Creating a dedicated team to work on the authorization process regarding treatment or service needed by the patient and ensuring complete clarity on terms and conditions provided by the insurer can help in avoiding negative consequences.
Trained coding professionals
Well-trained coding experts can help to avert coding problems, they will ensure code is as per the latest standard requirement.
Conduct audits and analyses trends in claim denials
Routine audits by tracking trends or patterns in denied claims, working on them, and improving them become easier tasks.
Ensure continuous and transparent communication with the insurer or payer because that will help in staying updated as per their conditions and contract requirements.
Effective use of automated software which helps in claim management by verifying patient information, treatment, or a service requirement with insurer conditions and by performing predictive analysis, denials could be evaded, and smoother management of denials can be experienced.
If you are struggling with denied claims and looking for outsourcing your medical billing then you can trust us. We are having a team of experienced Billers and Coders and our clean claim submission rate is above 95%. If you want to perform denial analysis in medical billing for higher reimbursement then you can get in touch with us.