Healthcare providers need to closely monitor any submitted patient claims that are later rejected by insurance payers. Many factors can trigger these rejections and denials. The goal is to investigate this issue, correct the problem; and then make sure it does not happen again.
If this problem is not remedied, a medical practice’s cash flow will experience serious disruptions. Clearly knowing which insurance claims are adjudicated and paid is essential for a facility’s revenue cycle. Sometimes outstanding balances are due to patient’s not fully understanding what portion of their insurance is their financially responsibility.
In situations where excepted insurance reimbursements are incorrect, there are usually four general reasons for this medical billing issue.
 Denied Claims: these are usually generated due to a patient’s insurance coverage not authorized to cover a specific therapy or procedure. The patient claim was submitted and processed but found was regarded as unpayable by the insurance payer. Language in the patient payer contract and similar reasons can create denied claims.
 Rejected Claims: these can occur when there is incorrect information on the insurance claim. Due to these errors, insurance providers will refuse to process the claims. A few examples of issues that often create rejections include mistakes in patient data or in the codes and modifiers that were used.
 Partial Payments: these commonly occur when only a medical claim’s specific line is paid. This means that the remaining procedures on the claim are not reimbursed by the insurance payer. In these situations, a good approach is to adjudicate the claim and monitor the progress.
 Overpayment: these are considered incorrectly paid claims by insurance providers. Initially, some healthcare practices are happy to receive additional revenue from an insurance provider. However, insurance payers will realize that they have made an error and will require that the financial amount be paid back in what is commonly known as a takeback.
Medical offices need to closely monitor their claim submission process. Initially, this seems like a simple task. However, problems can occur and quickly escalate. When this happens, healthcare providers and their support staff can find themselves spending an exorbitant amount of time on sending emails and making phone calls as they try to remedy these issues.
Patient’s Insurance Knowledge:
The fifth reason does not directly relate to insurance provider reimbursement polices and guidelines. Instead, this potential reimbursement problem has to do with patients and their knowledge of healthcare insurance.
Since healthcare practitioners are highly trained and knowledgeable, they sometimes assume that their patients are fully aware of their medical coverage.,
However, some patients may not fully understand what their health insurance plan cover. It will benefit both patients and healthcare providers if patients are aware of their coverage and financial responsibilities. When possible, medical practices should work to educate their patients about the main details of their insurance plan. In this way, medical providers can reduce the number of unpaid balances from their patients.
A few of the essential aspects of health insurance coverage that all patients should know include:
Copayment: This is the amount that an individual needs to pay out-of-pocket. It is considered a patient’s share of financial cost for a procedure or product. Examples can include prescription medication, office visits, outpatient treatments, etc.
Deductible: The amount that patients need to pay out of pocket before their insurance plan will start to cover financial expenses. After a specific amount is paid directly by the patient, their insurance plan will begin to pay the majority of the remaining healthcare cost. Basically, this represents the amount that patients pay before their insurance coverage starts to pay for a percentage of the health care expense.
Preauthorization: Insurance plans may require this in order to verify that a certain treatment, product or service is medically necessary. Sometimes known as prior authorization or prior approval, this action should be performed by the healthcare provider before a patient receives the treatment. Otherwise, the insurance plan may not reimburse the clinician for the procedure or treatment.
The primary goal is to reduce the amount of unpaid patient balances. An additional list of common insurance terms that patients usually encounter is available here.
In the end, if all five of these reimbursement issues are fixed and monitored, clinics and agencies will experience a much smoother back office. However, this is not a one-time process. Maintaining proper cash flow and minimizing aged accounts takes focus and long-term commitment.
As an Ohio-based company, Advanced Billing & Consulting Services (ABCS) provides innovative and experienced solutions for healthcare professionals. This includes medical billing, Ohio waiver provider agencies services, credentialing as well as online advertising services.
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