There are a few strategies that medical practices can implement when following up on submitted medical claims that have been denied by insurance payers. These strategies, when implemented, can greatly improve a clinic or practice’s denial management process.
Write Off or Follow Up:
A medical practice’s administrative staff should confirm that denied claims are not being automatically written off. Sometimes this is the default response for some office staff or certain practice management systems. Claim denials are usually noted on EOBs or similar reports. However, reports will sometimes list the denied line items with a zero payment and little supporting information.
If denied claims are mistakenly written off as a contractual adjustment, it is essential that this default response is stopped. Going forward, staff members should receive proper training on the payment posting and the medical billing process.
Offices should consider the various types of rejections they receive before assigning employees to work on these rejected claims. It is important that staff members have the necessary knowledge to successfully fix the denied claim and receive payment. To fully understand the entire process, medical offices should consider their entire practice staff, and not simply the members who are responsible for billing activities.
For example, if a clinic employs experienced coders and billers, they could analyze all of the claims that were rejected due to coding errors. These little details make a difference in the long run.
An experienced billing specialist can quickly determine the best course of action. Do the denied claims only need to be amended and resubmitted, or is more information from the patient’s medical file or doctor needed?
For example, if claims were denied because there was no referring physician or prior authorization, healthcare employees or front desk staff could work to remedy these errors from happening in the future. There are a variety of effective EHRs and PM systems that can distribute work to many staff members across a practice. At the same time, these systems can keep track of daily workflows, requirements and other billing developments.
Eventually, staff members can become internal specialists on the specific requirements of certain insurance payers. This is because the various insurance payers may have different claims denial management and appeal processes.
Assigning denials based on the original claim’s justification is frequently successful. But for some payer types, it is preferable to have one staff member handle all of a practice’s claim denials. This assigned employee can become familiar with the payer’s appeal deadlines, the appropriate forms as well as the overall appeal submission process.
Different Payer Appeal Processes:
There are distinct appeal procedures for various payers. Sometimes it is helpful for a trained and reliable staff member to assemble the major payers’ appeal procedures into a single staff-accessible reference guide. Hopefully, the denied claim is remedied in the quickest manner possible.
Often the most efficient process involves sending a revised, corrected claim, which is an easier process than a full claim appeal. Otherwise, the clinic or practice is forced to file the appeal through a payer’s web portal, email, fax, or phone. Naturally, there is a chance that this initial appeal will not be successful.
In these situations, healthcare practitioners need to more deeply understand an insurance payer’s formal appeals process for denied claims. This process can may include many levels of appeals and reviews. However, this approach can become a more costly endeavor. Practices should confirm with the payer all necessary actions and channels of contact before proceeding down this path.
Keep Denial Rates low:
Working through denied claims is often a tedious process. A medical practice may want to consider outsourcing this task. It is essential that competent personnel with experience in claims denial management complete this task. For example, there are different payer denial deadlines. If a practice’s billing staff misses this basic detail, they risk trying to appeal the denied claim after the appeal period has ended. Actions like these are a waste of time and resources.
By using these strategies, many clinics and practices can make their denial follow-up process more effective. All medical practices should try to adhere to the fundamentals of denied claims prevention. Lowering a practice’s denial rate creates financial benefits for healthcare clinics and practices. Claims are properly paid the first time and there is no longer any additional need for staff to spend precious hours working on denied claims.
About ABCS RCM:
ABCS RCM (Advanced Billing & Consulting Services) provides revenue cycle management tools for healthcare practitioners. Professional services include medical billing, insurance enrollment and credentialing monitoring services and website development for healthcare professionals.
Their account management specialists work closely with clinicians and integrate with their existing office EHR and PM software. This creates a partnership with personalized service with a level of flexibility that is able to adapt to the needs of each provider.
As an Ohio-based company, they also provide software tools and billing services for agencies that provide supports for the Ohio I-DD community.
To learn more, email or call them at 614-890-9822. Follow and like ABCS RCM on Facebook, Instagram and Twitter:
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