Identifying the reason for denial and resubmission is a prolonged process. To keep your revenue cycle management streamlined, building a claim denial management strategy is important. If you have fewer clear claims, your business will not be able to get a good cash inflow. To improve the cash inflow you must use denial management solutions
Previously, the healthcare claim denial rate was 5 to 10%, which increased to 23% in the last few years. For healthcare facilities, the denial of the claim is unpaid services, lost revenues, and a decline in the business’s financial health. One can notice that among these denied cases, you can recover most of them. By adopting a better claims management strategy, you can avoid maximum denials.
To save your claims from denials or rejections, you must check your claims submission completely because most of the claims denials are due to misinformation. It is important to keep claim denial below 5%. Your denial management strategy defines the acceptance rate of claims. In this blog, you will be able to learn how denial management solutions can help businesses.
Definition of Denied claim
Commonly Healthcare claims rejection and denials terms are used interchangeably. These two terms are different. It would help if you differentiated between rejected claims and claims denial.
A claim rejection contains the errors of formatting, billing or coding errors, and incomplete data. The rejected claim is not considered as received. You can resubmit the claim after necessary rectifications.
A denied claim means you have submitted this claim late, and it is impossible to process it again. The insurance company will send you an “Explanation of Benefits” or “Electronic Remittance Advance” to explain the reason for denial. You must check the reason for denial before resubmission.
Types of denials
There are two types of denials
You cannot reverse a hard denial.
Soft denial is not permanent. You can get paid for the claims under soft denials if you correct the error or add the required information.
What is denial management?
First of all, it is important to know what denial management is? What are the claims denials and rejections?
Denial management is the process of rectifying, resubmitting, and getting paid for the claim submission. The task of the denial management team is to identify the errors in registration, billing, or coding and correct them. The team also analyzes the payment patterns of the insurance companies.
Errors and Difficulties in Claims Denial Management
The major difficulties in claims denial management and their solutions are
To check and recheck documentation is time-consuming. Your staff will require weeks to analyze the claims before resubmissions. The time frame of rechecking can stretch from 5 minutes to 5 hours. At the same time, the chances of the error remaining unidentified are also present.
Insurance companies give limited time to process the claims submissions and resubmissions. Medical practitioners and facilities have to write off claims because of submission time. Medical Group Management Association reports the cost of the denial process is $25. At the same time, there is no reworking of 50% to 60% of claims because of a lack of time and knowledge. You can adopt denial management solutions to improve your productivity and efficiency.
Different causes of Claims denial.
The major causes of claim denials are three categories
You can rework the claims with administrative errors. After removing these errors, you can resubmit the claim to the insurance provider. You must submit an appeal for the claims for clinical or policy reasons. You must send the appeal through certified or registered mail.
The first step in denial management is to identify the cause of denial. The second step is to determine the steps for appeal. You must establish a comprehensive workflow to track and follow up on your claims.
The important thing to remember is “Don’t Delay.” Speed up your process up to the maximum limit. In case of denials, review, rectify, and resubmit in less than a week.
A duplicate claim
Always remember to check whether it is in process or not. Secondly, the rejection is from the clearinghouse; check for the reason and then work to resolve the query.
Health Plan coverage
Check for the “Patient eligibility for the specific service.” It is important to check whether the health plan coverage is still on the go or has ended?. Ensure to verify the correct filing address and other important information.
Is your credentialing process completed?
It is also important to check that you are credentialed in a specific area of the insurance provider network. Start the process if your credentialing is missing in the insurance plan area. Make sure to get the credentialing process as soon as possible.
Missing or wrong patient demographic information.
A patient’s basic information is an important thing while submitting the claim. Even a minor change in the Patient’s spelling, name, date of birth, or medical plan number leads to denial. These minor errors are also difficult to track.
Exhausted number of services.
It is vital to confirm that the patient service limit is not exhausted. Many insurance providers allow a limited number of visits or services per year. If the limit exceeds, the insurance company is not liable to pay the service provider.
Prior Authorization number
In the first step in the revenue cycle management process, It is important to get authorization from the insurance company even before the Patient’s first visit. You must cross-check the authorization number before claim submission.
A missing or invalid service code
The insurance company will reject your claim first if the procedure codes are missing, outdated, or a digit of it is missing. Link only appropriate documentation according to the requirement.
Strategies for the effective claim denial management
The following the strategies for effective claims denials
Submit Clean Claims
The important strategy to avoid claims denials is clean claim submissions. Every healthcare practice aims to get the payment on the first submission. You must submit clean claims to avoid the hassle of resubmission and reworking.
The chances of getting payment for clean claims clearance are more than the chances of reimbursement for denied claims. Healthcare providers can adopt cloud-based denial management software and systems to get quick and cost-effective claim submissions.
Separate billing for each service.
You must bill every service separately because, in some cases, the bundled billing is unacceptable. Bundle only those repeated or multiple tests that require minor procedures.
The Place of Service POS
Place of service is another important factor to check before claims submission. Ensure the POS code is the same as the Patient received face-to-face care. Or, if the test is performed in a separate place, use the specific code.
Local Coverage Determination Policy
It is important to check the local coverage determination policies of the insurance payer. Usually, the insurer’s website has this insurance policy. Check it before the provision of service.
Meet the Dead Line
Meet the deadlines. The deadlines for claims and denial management of every insurance company are different. Some insurance companies allow 30-90 days from the service date to claims submission. The insurance company will deny your claim if submitted after the deadlines. Outsourcing denial management services will help you to manage your claims efficiently.
Invest in an efficient Claims Denial Management Solutions
The denial management service provider closely checks credentialing, Patient eligibility, coding, and entry before claims submission. Deploy denial management software to get more payments with less labor cost. Take a deep look at your practice revenue cycle management to determine the type of software that suits your facility. The denial management software must integrate with practice management and billing software to make things easier for your staff. Outsourcing a medical billing company with denial management solutions will help you to enhance your overall financial health.
Frustrating job made easy.
Denial management is time-consuming and frustrating, whereas denial management solutions help healthcare providers drag them to ease. Healthcare providers must resubmit claims after solving the errors.
Data Entry analysis
Add another step in your revenue cycle management: data entry analysis. Before claims submission, you can verify and counter check complete record by yourself. If you have an in-house team for claims submission, you can deploy a separate person for counter check or pre-audit. If you outsource denial management solutions, the medical billing company must check the complete documentation of the claim before submitting it to the insurance company.
You must deploy the denial management solutions with an automated alert generation system. Your denial management systems must notify you of claims resubmissions and claims status. This automated alert system helps give on-time responses. Your on-time response will save your company from losses, claims denial, or writing off.
Automated denial Management Software
An automated claims management software will help you reduce the denied claims from piling up and remaining unattended. Investing in denial management software automates the claims management processes. It will streamline your revenue management cycle.
The automated denial management software analyzes the denied claims on time. The on-time process of correction and resubmission helps you maintain the regulated inflow of collections and profitability.
Your claims denial management software integrates with your existing billing and revenue management cycle software.
A medical billing company with experienced and certified coders can provide you with a claim scrubbing facility and submit an error-free claim. BellMedEx provides specialized denial management solutions to streamline your revenue cycle management.