Avoiding Common Healthcare Errors in Denial Management

Denied claims are something healthcare providers should be most concerned of as if claims are being denied that means reimbursements are directly being affected. Denial management are often confused with claim rejection. Rejected claims are the claims that are rejected straightforwardly either on account of errors or the payer determines them as rejected and they have to be corrected and submitted again. On other hand the denied claims are the claims insurance companies have decided not pay. There could be numerous reasons for claim denials and they have to be carefully investigated and appeals should be made to secure the delayed or lost revenue.

What is Denial Management?

Denial management process involves many things like tracking the denied claims, identifying the issues, appealing and resolving the denied claims from insurance companies. Reasons for denied claims can be due to prior authorization issues, eligibility, non covered services, incomplete documentation, late claim submission, coding errors and lack of necessity. The denied claims can have significant impact on the financial health of healthcare organizations or individual physicians therefore denied claims have to be taken care of on time with utmost seriousness to avoid the financial dent.

To make effective appeals the medical billing professionals go through the process and perform analysis to identify the root causes for claim denials. Once the causes are identified they make every effort to correct the issue and rectify the errors and prepare an appeal to the insurance company. To be successful and grow in the healthcare industry the healthcare providers must continuously look into the issues of front end processes, this is how they can prevent denials to happen in the future.

Reasons of Claim Denials

Incorrect Patient Information

Incorrect patient information such as insurance policy number, patient name and date of birth errors can result in a claim denial.

Lack of Prior Authorization

In some cases insurance companies ask for prior authorization and if the services are provided or procedure is done without getting prior authorization, it can become a cause of denied claim.

Coding Errors

Wrong procedures and diagnoses coding along with other coding errors can cause claims to be denied.

Non-Covered Services

A denial management will occur if the service provided is not covered under the patient’s insurance policy. Medical practices should always verify patient coverage and benefits before rendering services.

Duplicate Billing

This occurs when you bill the insurance company for the same service twice or multiple times.

Late Claim Submission

To avoid the most common denials, you should submit your claim within a specified timeframe.

Lack of Necessity

If in case insurance companies determine that the diagnoses codes used do not support the need for the patient in any particular scenario, they can deny the claim. 

Tips to Avoid The Errors

Denied claims hurt the financial health of healthcare providers and lost revenue is the most concerning thing for physicians and healthcare organizations therefore knowing the reasons and avoiding them to happen again in order to reduce claim denial rate is inevitable. To avoid claim denials physicians and healthcare organizations need highly trained and experienced medical billing professionals and in most of the cases outsourcing the revenue cycle management to the competent medical billing companies like The Medicator’s is the best option to save cost and hassle. The Medicator’s provides error free medical billing and denial management services in order to increase the reimbursements and financials of healthcare providers and organizations across the united states.

Double Check The Patient Information

Patient information on claim form is very important to be taken care of. To ensure the provision of correct information it is necessary to have correct information in hand. Once the information mentioned make sure to double check the information and eliminate the chances of any errors.

Ensure the Eligibility Verification

It is very important to collect patient’s insurance information verified even before the patient is enrolled in the healthcare facility in order to avoid the inconvenience of claim denials. Therefore before taking the patient into the procedure make sure that the eligibility verification is done to avoid revenue losses.

Check of Prior Authorization

In some cases the insurance companies ask healthcare providers to get prior authorization certifications before taking the patients into the specific procedures. If the services are rendered and claims are submitted without procuring the prior authorization, the insurance companies are supposed to deny the claims. Make sure if there is any requirement for prior authorization then it is procured before rendering the services.

Avoid Coding Errors

Coding errors are among the top reasons for denied claims. Having CPC certified coders onboard is very important in order to ensure correct diagnoses and procedure codes.

Ensure The Claimed Services are Covered

In order to avoid the claim denial management it is a must to check if the services rendered are covered in the insurance program the patient is coming with. In case of making claims against the services not covered, the insurance companies are supposed to deny the claims.

Submit Claims on Time

In time claim submission is the key to seamless billing process and timely reimbursements. If the claims are submitted within the given time window they are unlikely to be denied and processed in time. The claims submitted after the given time period are very likely to be denied and will need to be taken into the appealing process which will cause the delayed reimbursement and time wastage.

Ensure The Necessity

Sometimes insurance companies determine a claim having no need for the patients against mentioned diagnosis and procedure codes. In these kinds of cases the insurance companies deny the claims. To avoid this situation it is very important to obtain the medical necessity guidelines from insurance companies and to comply with these guidelines to avoid claim denials.

Summary 

To ensure a better financial health for healthcare organizations and physicians it is very important to avoid claim denials that cause the delayed or lost revenue. To ensure the claims are not being denied it is very important to understand the reasons for claim denials and then make your billing process so efficient and vigilant which can avoid those mistakes and ensure seamless billing and claim processing. Highly trained and experienced staff or outsourcing you RSM to a very competent revenue cycle management company can save you physicians and healthcare organizations a lot of money.