Connections for Success

 

01.20.22

What Can You Do About Claim Denials?
Kelly H. Buchheit

Among the most essential characteristics of a financially healthy medical practice is claim acceptance and timely payment. In the current volatile economy, it is even more important to ensure that your billing process runs smoothly and that you avoid bumps in the road caused by too many claim denials. Here are some ways to increase claim acceptance.

Related Read: Five Financial Strategies To Improve Your Practice’s Profitability

What is the goal?

The goal for your practice should be to have its claims accepted on first submission. This requires taking steps early in the revenue cycle. To begin the process, identify and record the exact reason for every claim denial. Consider using a denial management module built into your overall practice management system to do this quickly and easily. A denial management module will allow for tracking a variety of distinct claim denials.

For example, the payer may insist that the stated diagnosis does not support the medical necessity of the services. Another instance may be due to missing paperwork in the documentation for the claim. Another reason might be that the patient may not be a covered beneficiary of the payer to whom the claim was submitted.

The various reasons that emerge should guide your practice to take two types of actions: 1) Immediately correct the errors to reverse the denial; and 2) Modify your practice processes to prevent the errors from reoccurring.

Related Read: Keys to Improving Your Revenue Cycle

How should you respond?

There are several possible responses to a claim denial. Once the root cause of the denial is established, you can resubmit the claim. Doing so might involve:

  • Locating missing paperwork;
  • Correcting inaccurate codes; or
  • Changing the name of the patient’s insurer.

If the payer refuses to accept the correction, but you believe you have submitted the proper documentation, your next move may be to file an appeal. You will need to contact the payer to learn its reasoning on the matter. Then, you must prepare persuasive arguments in support of the claim. As appropriate, gather additional relevant documentation or obtain more expansive statements of medical necessity from your clinicians. Finally, file the appeal and follow up with the payer every two weeks until the matter is resolved.

If an appeal proves unsuccessful, you may have no other option but to drop the matter and write off the charge. A write-off is necessary if the practice cannot locate the documentation to support the claimed service or if it turns out that the service was part of a bundle that already has been paid separately and never should have been claimed in the first place. Nonetheless, a write-off should be the last resort to a denial.

How can you improve your process?

Claim denials and write-offs should be tracked by contract, which will point out the need to make systemic changes for the future. Problems such as incomplete documentation or improper coding may indicate a need to retrain your staff and clinicians.

Focus on getting all the right patient information before or during registration and capturing and entering the correct charge codes in a timely manner. Also, correct pre-adjudication edits are returned daily by the claims clearinghouse.

Stay on top of claims

The best way to handle the claims challenge is to stay on top of your billing process and make ongoing corrections as needed. Have your billing department generate periodic claims reports and create forecasts of future trends based on those reports. This will provide an accurate picture of how your practice is handling claims and ensure you stay on the road to success.

For more information, contact Kelly Buchheit at [email protected]. Visit ORBA.com to learn more about our Health Care Group.

  1. Thanks Kelly,
    Good read and thanks for these tips.

    While we continue to make improvements,
    We also have unique issues with certain MCOs inefficiencies and errors in payments and errors in denying claims etc. that can take up to one year for a final disposition.
    It would be interesting to know how other FQHCs are doing.

    Erlinda

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