The obvious question should first and foremost be, “Why are my claims being rejected in the first place?” For the majority of specialty practices, claims are typically denied as a result of data-entry errors and other basic errors such as:
Accordingly, we can’t overstate the importance of collecting the right patient information, and all of the critical data that will be needed, up front. Several methods that can simplify this endeavor include:
By no means are these fail-safes for preventing denied claims, however. As we’ll explain later in this post, insurers can be finicky in what they choose to accept. Nevertheless, these efforts will help to significantly reduce the number of rejections that result from erroneous or out-of-date patient data.
When the time comes to actually create claims, prevention is once again the first part of any strong denial management strategy. Specifically, we recommend that practices analyze and scrub all claims to identify potential front-desk errors that occur after creating the claims, but before submitting them.
The sophistication and interoperability of your information systems (EHR, PM, Clearinghouse, etc.) are critical here, as they can do much to verify the accuracy of procedural codes and other claims data. Much as a word processor might be able to provide a recommendation for a misspelled or out-of-place word, these systems can automatically check input values against data recorded in your EHR’s clinical libraries and patient records. This can preemptively flag entry errors that lead to denials.
The second part of your denial management strategy is the contingency plan:
Rejected claims submissions will often expire as a result of slow re-submissions and backlogs. This bottleneck, in itself, represents a common source of denied claims.
For this reason, it’s essential to have a formal denial management strategy – first by figuring out how to enhance the claims scrubbing process, and second, by creating a formal workflow for dealing with denied claims in a timely manner.
While a strong PM can help catch some claim-processing errors, we would also recommend staffing experienced personnel to manually check claims. Insurers have been known to accept a claim one month and reject a nearly identical claim the next, meaning there is an element of industry experience to consider here.
For practices that don’t necessarily have the staff on-hand to perform these checks, a partnership with a third-party billing and claims scrubbing vendor can serve as a viable substitution. This option is typically far more cost-effective than hiring and managing an in-house team.
Likewise, referring to external experts who can follow-up on denied claims can help practices avoid falling behind in their pile of rejected claims. More importantly, though, these RCM experts can identify the common sources of denied claims and provide deeper insights into the corrections and workflow improvements that can make for dramatically better and more efficient bottom-lines.
Billing and coding activities are often interrupted by other, day-to-day concerns that your staff simply can’t ignore. Indeed, many in-house billers are already providing double-duty in other administrative and clinical areas. This makes it difficult, if not impossible, to give claims scrubbing and denial management the attention it deserves.
AllMeds billers and coders, on the other hand, focus on billing and coding for specialty practices throughout the day – it’s what they do, after all.
We provide your practice with certified and qualified staff members, which is a welcome relief, considering the difficulty many practices experience finding, attracting, and retaining certified coders and billing staff. Experienced medical RCM talent is in high demand these days; consequently, the cost of staffing qualified in-office billing and coding experts is increasing to the point of becoming prohibitive for many practices.
With our experts at the helm of your denial management operation, you save money and time that might otherwise be spent recruiting, paying and managing costly in-house RCM teams. You also don’t have to worry about balancing day-to-day staffing issues such as illness, vacation, maternity leave, family leave and so on. We make sure that highly qualified experts are available, when you need them to be.
And your existing staff? We train them and maintain their knowledge of constantly evolving coding requirements and payer rules. This is an especially critical component of our RCM services: What works now might not work six months down the line, based on a slew of factors such as regulations, the development of new payment models (e.g., VBC and ACOs) and much more. Our staff can also assist your staff with their hard-to-collect accounts in a diligent, experienced and professional manner.