By Michelle Crawley

Ask a physician about their biggest pain points when it comes to the physician billing process, and they’ll frequently mention denials. A denied claim is a claim that the payer has processed and refused reimbursement based on one or more factors.

No one wants their medical payments to be denied because spending time appealing a denied claim and sending it back to the payer for processing increases administrative costs and delays cash flow. That’s why it’s important to prevent denials in the first place. While you certainly want to work any denials that do occur, it takes more time to fix a claim than it takes to get it right the first time.

Etiology of denials

There are several common causes of claim denials, including:

♦  Ineligibility
♦  Procedure not medically necessary
♦  Preauthorization required
♦  Provider out of network
♦  Incomplete information
♦  Incorrect patient information (sex, name, DOB, insurance ID number)
♦  Incorrect provider information (NPI, address, name, contact information)
♦  Incorrect insurance provider information (wrong policy number, address)
♦  Duplicate claims
♦  Improper coding / issues with ICD-10
♦  Untimely filing

Fixing the problem

It’s important to have internal processes in place that can find and correct mistakes before a claim is submitted.

Consider investing in automated systems that help to flag potential errors before the claim leaves your office. A revenue cycle management (RCM) service can handle all aspects of the billing process. When properly integrated with an electronic health record (EHR) or a practice management (PM) system, the process can be streamlined and administrative mistakes can be reduced from patient check-in through final billing and reimbursement. Data is shared and claims can be submitted faster.

With this integrated technology, procedures can be incorporated into the revenue cycle workflow, such as:

8 Tips for Physician Practices

1.   Scanning photo identification and insurance cards at every patient visit.

2.   Verifying insurance eligibility ahead of time.

3    Using an EHR to submit CPT and ICD-10 diagnoses.

4.   Verifying patient information is correct.

5.   Performing claim scrubbing. This is the term for reviewing claims before they are submitted, in order to ensure they are correct (or clean) to meet guidelines from insurance companies. This can be done manually or through billing software or an RCM service in order to prevent rejections.

6.   Posting alerts and notifications to submit changes within 48-72 hours of the date of service.

7.   Electronic submission (or resubmission) of the claim to expedite reimbursement.

8.   Consistent, timely follow-up on unpaid claims.

Don’t just write off denials. Get the tools you need to assist your staff in minimizing them to help with reimbursement. Having a low denial rate demonstrates a healthy cash flow and allows your team to focus on what matters most: administering patient care.

Michelle Crawley is a marketing specialist for Quest Diagnostics Quanum portfolio (formerly Care360). Quanum’s Electronic Health Record (EHR), Practice Management (PM), and Revenue Cycle Management (RCM) clinical and financial solutions help physicians analyze, connect, and engage for better outcomes. To learn more about Quest solutions, call 1.888.491.7900.