2/28/2017 0 Comments 5 steps to managing denied claimsWhen we think of insurance companies and denied claims, we often think about children. They are always toeing the line and begging you to say something. Then, they finally cross the line and get your reaction. They (The insurance company. Not children.) deny your claim and you appeal. Over and over again. It's like a never ending cycle. But then you get tired. "It's just $50," you say. Then you get angry. You start huffing and puffing at the computer and you complain to your spouse when you get home because the insurance company doesn't understand why this service or procedure was necessary. (Pro tip: Your spouse doesn't care about denied claims. Just leave that one at the office.) A comprehensive article on claim denials would take longer to read than the classic novel Les Miserables, but our goal here is to give you five simple steps to that will put you on the path to a better life. So here we go. Five ways to manage claim denials!
1. Prevention: You've heard the phrase, "The best offense is a good defense," right? Well, it doesn't only apply to sports. Preventing denied claims is one of the best ways to ensure your practice is getting the funds owed to it. Avoiding denials related to coding mistakes is key. One of your top priorities should be to make sure your services are linked to the correct diagnoses and that the proper modifiers are used alongside them. In addition to errors in coding, filing to the incorrect payer probably happens more often than you realize. The small details like misspelling a patient's name or an inaccurate date of birth can also result in long reimbursement delays. Having solid systems and processes in place to monitor and avoid this is crucial. Every second spent re-filing an insurance claim costs your practice money and these costs add up quickly. Make sure your staff is checking patient eligibility to be aware of referral requirements, any needed pre-authorizations and if your practice is out of network. A full understanding of patient eligibility will help you avoid resubmissions, payment delays, or denials. 2. Timeliness Denied claims are just going to happen. That's something we all know and understand. But if you are doing everything you can to prevent them, the effect they have on your practice should be minimal. When rejections do come, however, one of the biggest mistakes you can make is waiting to work them. The most obvious reason to avoid waiting is that it will take longer for you to recover your reimbursement. The goal of any business is to get paid as quickly as possible for services rendered so avoiding delay with regard to denied claims should be a top priority. You and your staff should have a specific process in place to guarantee that rejections are handled in a timely manner. Processing these claims on the same day and time each week is an easy way to make sure getting reimbursed for rejections doesn't slip through the cracks. One of the most important pieces of your practice's claims process will be setting expectations for responding to denials and holding your staff accountable for reporting back on progress. In addition to fighting the natural instinct to put off working denied claims, some payers have stingy filing limits. If you are procrastinating working rejected claims you could easily be in danger of missing a short timely filing limit. 3. Read and understand your EOBs In most cases, the explanation of benefits (EOB) included with the returned claim will have a brief explanation about why the claim was denied. The EOB is essentially your map to the denial reason and it is well worth your time to get familiar with each provider's "remark code lingo." One of the most important reasons to understand the provider EOB is that it keeps you from having to dial the customer service line and spending an exorbitant amount of time on the phone. Truly understanding your EOBs will help you figure out the correct solution and develop a faster course of action. 4. Know your revenue cycle Part of knowing your revenue cycle means knowing each insurance company's payment cycle. For this specific step, getting in the habit of checking the claim status for claims that have not been denied but also haven't been paid is very important. For example, if you know Blue Cross Blue Shield usually pays in 10-15 days, but it has been 30 days since the claim was submitted, you can log onto their website and check the claim status using the online claims portal in order to make sure you didn't miss something from the insurance company such as a requests for medical records. We won't mention any names here, but some insurance companies are notorious for "pending" claims without notifying the provider that they want to review medical records or something similar. Fair or not, the onus is often on you, the provider, to keep tabs on claims with these companies in order to ensure they get the documents they need and that the claim gets processed. One of the best ways you can keep track of outstanding claims is by using your insurance aging report. Setting specific policies and procedures within your practice to follow up on outstanding claims as they age will prevent denied claims from falling through the cracks. 5. Utilize payer websites Understanding the ins and outs of each payer website can be a challenge, but the investment is often one that pays off in the long run. Most payers have resources on their website, such as coverage policies, that spell out exactly what they require for each service. The information and language used in these policies can and should be used to support your appeals. In addition to policies, many payers have online portals that help you obtain status on pending claims, which helps you avoid the dreaded calls to payer customer service. Some will even let you file appeals online to avoid delays or lost mail from the postal service or in the payer's own mail room. For many smaller practices, being able to file claims directly on the payer's website is very useful since they are likely too small to have a practice management system that files electronically on their behalf. Again, the purpose of this article wasn't to reinvent the wheel. Instead, we wanted to offer a reminder of some simple, yet often forgotten, ways to minimize the effect of denied claims on medical practices. As always, we want to hear from you! Reply to this email and let us know how you and your staff handle denied claims.
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AuthorThe staff and doctors at VisionAmerica are committed to providing relevant information for you, your patients and your practice. We hope you find the information in our blog post helpful. Archives
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