One critical reason why providers opt to outsource medical billing is having to face frequent claim denials. These are major buzzkills of the healthcare market. It is probably the biggest challenge face by the practitioners in going forward with a profitable practice. Taking the extended time-period for receiving reimbursement into account, denials pose a nasty blow to the account receivables. And it reflects so badly on practice’s bottom line.
When the providers outsource medical billing, claim denials are managed in two ways;
- Doing the necessary damage control by sorting out the reasons for denial, and working on the claim again to obtain reimbursements
- Determining the pattern of errors leading to denial and assisting the practices to revise the process so that no more denials happen
Let us look into both of these in detail;
Denial Management Process
When you choose to outsource medical billing, the expert denial management team will thoroughly review the claim document and pin down the key reasons that lead to denial. They also look in to the reasons provided by the insurance companies for denying claim.
Next step is to categorize the denials as per the reasons, and alert the respective department to obtain the necessary documents to perform a revision. Appeal letters will be design based on legal grounds stating Federal and State treatment charging policies, for getting reimbursement on the deny claims. The appeal process will be follows up and the provider will be informs of its status.
One advantage when you outsource medical billing to expert professionals is that they are proficient in appeal process at various scenarios which can guarantee payment for denied claims at any cost.
Denial Preventive Measures
Practices outsource medical billing to get help with interpreting the nature of their frequent claim denials. Once the experts can figure out the root cause and pattern of denials. They are studied in detail to realize the size of financial loss it brings on. Next step is to identify from which step of the billing process the errors are arising from. Only if the denial patterns are thoroughly analyse one can tailor the measures to rectify them.
According to the pattern of denials, the claims will be category based on the type of errors commit. This gives an opportunity to tweak the workflow for process improvement. Sometimes the providers and healthcare staff along with billing staff are going to have to undergo a training regarding the updated claim practices. Sometimes the practice management system and revenue cycle might need a total restructuring to prevent these denials from surfacing again.
Key Factors Leading to Claim Denial were Identified as the following
- Incorrect demographics -data entry- Most of the time, the front-end staff mis-spells or miss out on the names and numbers involved in demographics data collection. Even the slightest oversights in this area will lead to claim denials.
- Coverage verification and preauthorization issues- These two are very crucial steps to be take before the patients comes for a visit. The existing status of the patient’s insurance subscription should be look into and made sure it is valid. The type of treatments cover under their plan and under whose name the insurance is register should be verified too. Claims often get deny for these reasons
- Improper documentation- The EHR should be in a fully comprehensive and unambiguous manner so that coding and charge capture is easier. The documents should be able to support and validate each service coded and billed in the claim
- Coding malpractices- The most common errors leading to claim denials are pertaining to coding errors. Every time there is a mismatch between the code enter and the treatment render claims are denied. Not adhering to compliance standards while coding is consider a federal violation as well
The specialist who manages the denied claims will alert the administers and practice managers regarding the errors in the process. With this they can make informed decisions to make the necessary revisions in the process. The analysis reports will be elaborate enough with recommendations to prevent future denials. When you outsource medical billing, existing claims will be screened before sending out to the payer and those with higher chances of getting denied will be rejected at that stage. The reject claims will be list out with cause of rejection for better understanding of the billing staff.
Once the new strategies for eliminating denials are establish. One has to monitor the process periodically for adherence to the set standards. When the providers outsource medical billing, a part of the service is frequent chart audits and billing audits to make sure compliance is ensured and process is full proof. Experts can also give suggestions and guidance to bring about better claim processing strategies. By implementing technological advancements to the practice. Each stage of billing and charge capture will be critically scrutinize. So that process improvements can be establish for running a profitable practice.
