Payers may deny reimbursement for any number of reasons — some reasonable, others arguably a bit arcane. Consider revamping your workflow to include a process that will not only identify denials but will provide a firm foundation to get them reversed.
Integrating denial prevention into this strategy can do more than get you paid now; it will protect your revenue stream and success in the long term. Payment challenges emanate from pre-adjudication clearinghouse rejections, as well as payers’ claims processing denials. Here are some quick strategies for independent practices to address the most common sources of non-payment.
The most common denial relates to insurance eligibility. It’s not uncommon for a patient’s insurance to have lapsed or changed without informing their provider’s practice. To avoid these denials, it’s vital to confirm insurance coverage and conduct eligibility checks prior to the start of the appointment.
This financial clearance process makes your practice's billing process much more effective when you integrate it into your scheduling and intake workflow.
Anticipate referrals and authorizations
Make sure providers and staff understand payers' requirements in this area and prepare to meet and even exceed them. Most payers allow for authorizations to be granted via an online request process. Regardless, save all correspondence in the patient’s account.
For telephone communications, keep copious notes, and be sure to note the:
- Reference number
- Representative’s name
- Payer representative’s extension number
Recognize medical necessity
Be aware of payers' medical necessity policies, and prepare to discontinue, write off, or have patients pay for services that a payer won't cover (unless contract restrictions disallow this tactic). Consider these questions to establish denial management best practices:
- What services are payers denying for medical necessity?
- Are the denials valid?
- If you appeal the denial, will the payer reconsider payment?
- Does the payer outline any policies that will reveal a potential denial for medical necessity before the service is performed?
- Engage the patient in a 3-way call with the payer; patients can be the practice’s top advocate for obtaining payment
Understand payer coding
Research payers’ coding policies and learn what to expect. When preparing to work with a new payer, consider these questions:
- What services are other payers denying due to incorrect coding?
- Does the payer follow the prevailing national coding guidelines, such as the recognition of modifiers and the Correct Coding Initiative (CCI)?
- Does the payer outline any policies that can reveal in advance whether a service will be denied because the payer considers it as a bundled service?
- Are you familiar with payment policies — from multiple procedure reductions to payment for unlisted procedure codes — for your practice’s common services?
The majority of denials are caused by errors made at the front desk. The single task that front-desk staff can perform to reduce denials is to capture the correct insurance and demographic information from patients. If this isn’t accurate, the claim can go to the wrong party.
Additionally, denials based on incorrect insurance or demographic information are high-probability candidates for write-offs because the effort to re-work them often exceeds the payer’s timely filing deadline. That's why it’s important to have a good claims submission and management process.
“The single task that front-desk staff can perform to reduce denials is to capture the correct insurance and demographic information from patients. ”
Rejections and denials are most commonly caused by staff error. Auto eligibility checks and other practice management software features can help flag and/or correct errors.
Reduce denials to increase income
There’s no single ideal route to implementing denial prevention and remediation. You can take the do-it-yourself (DIY) route or seek the assistance of software or a medical billing company. Some practices use sophisticated, automated denial management processes and systems to send claims appeals based on the payer’s reason for the denial code.
Whether you choose the DIY approach or rely on intricate tools, never automatically write anything off. You provided the service and deserve to get paid. It’s up to your practice’s team to doggedly pursue payment while implementing internal process improvements to increase your payment success rate.
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