For any medical practice receiving accurate insurance, and reimbursement is a challenge. A high number of denied claims is a prime reason as practices lose a huge amount of money. In this article, we shared ten (10) basic tips that will help in reducing claim denials and ultimately result in increasing insurance reimbursements. Most of the tips mentioned below will require a medical biller and/or coding expert who will conduct all these activities on regular basis.
Collect Accurate Patient Data
Any mistake in collecting patient data will directly lead to claim rejection and ultimately delayed payments. Collected patient data like patient name, DOB, sex, insurance payer, policy number, group number (if applicable), patient’s relationship to the insured, and primary insurance (in the case of multiple insurances be accurate and up-to-date must be accurate and up-to-date. Most of the time, collecting patient data is the responsibility of the front desk team. As it forms the base for eligibility and benefits verification, It’s very important to step in receiving accurate insurance reimbursements.
With more and more patients opting for High Deducting Healthcare Plans, considering every patient has active insurance coverage could be a big mistake. You need to verify eligibility and benefits for every patient visit. With eligibility and benefits verification, you will get details like covered procedure codes, plan’s active coverage, maximum benefits, and need for prior authorization. In the case of non-coverage, you can ask for secondary insurance details or ask patients to pay as self-pay.4
Authorization and pre-certification issues account for 18 percent percent of denials. It takes time to learn which services are considered medically necessary, which require prior authorization, and which require referrals. And, obtaining prior authorization doesn’t guarantee payment. The claim also must be supported by medical necessity, filed within the deadline, and filed by the provider noted in the referral or authorization. To stay within the bounds of medical necessity, only perform a procedure if there’s a clear medical reason. Use notes or attach records to support the services provided.
The best way to reduce denials is by coding to the highest level of specificity. This often means coding up to the fifth digit. If you are using an outdated codebook or your coder or your biller enters the wrong code, your claim could be denied. If your practice depends on a hospital or other facility to provide procedure or diagnosis data, make sure that the chargemaster and diagnosis listing contains the most current version of CPT, HCPCS, and ICD-10 codes. Always stay on top of revised coding guidelines to ensure minimum denials.
Understand Payer specific Rules
On average, any provider will accept around 15-20 insurance plans. Understanding payer requirements will ensure accurate payment and reduce denials. Rejections for procedures not covered can be avoided by checking details in the insurance eligibility response or calling the insurer before providing care. Insurance carriers keep on publishing billing and coding guidelines and any updates for provider education. You can even subscribe to payer newsletters for staying on top of billing and coding updates.
Timely Claim Submission
Each payer has a deadline for submitting claims, editing claims, or saving them only as a draft may delay claim submission. Ideally, you must submit an insurance claim within 24 hours of a patient visit. More quickly you are submitting the claim, you will be getting paid quickly. Submitting a clean claim is important but it should have a deadline.
Monitor Billing Cycle
Submitting a claim and waiting for payer’s response could be a long way. If you are waiting for a payer response, you might have lost at least 2-3 weeks’ time. Rather than, start monitoring every billing process independently. Take a close look at mid-cycle tasks, including documentation, chargemaster set-up, charge capture, and
What the billing team codes may be different from what the provider meant in the documentation or transcription. Unfortunately, this discrepancy can have a severe financial impact. If a service is not documented, you will not get paid. Clear documentation helps ensure proper coding the first time. Your documentation should include the specific diagnosis, details related to the procedure or service, and patient history. Documentation is deemed insufficient if it doesn’t adequately support payment for the services billed or if a required document is missing. If your practice is receiving denials related to documentation, work with your providers to find ways to improve the process.
With constantly changing billing guidelines and payer reimbursement policies, it’s essential for every staff member to be knowledgeable and updated. Your front desk staff must be able to read benefits reports and if a patient calls, must be in a position to discuss that report with them. A well-informed and updated staff member will assist in receiving maximum patient collections.
Outsource Medical Billing
Most small practice owners, handle medical billing all by themselves. They tend to use a specific set of procedure codes for all their patient visits. This could draw payers’ attention to your practice and can lead to external payer audits. Medical billing and coding require in-depth knowledge and understanding of billing terminologies, billing scenarios, payer guidelines, and reimbursements policies. So, rather than doing all by yourself, hire a professional medical billing company like Medisys Data Solutions for receiving increased insurance collections.
Medisys Data Solutions can assist you in receiving accurate insurance collections for delivered care. Our expert billers and coders assist you in submitting clean claims on a timely basis. To know more about our complete medical billing services, contact us at firstname.lastname@example.org / 302-261-9187