Medical billing denials are the nightmare of every healthcare provider. It is a major burden for healthcare practices that has the power to negatively impact the revenue cycle of the organization. This concern needs to be addressed fast and accurately.
For addressing this issue, the healthcare manager should have comprehensive and right understanding of the common mistakes and the prevention strategies.
In this blog we will shed some light on denials and how you can manage them. We will go through some of the crucial aspects that aim to equip healthcare providers with the necessary knowledge and maintain denials effectively.
Importance of Denied Medical Claim Management
Denials are directly linked to the financial performance of a healthcare practice. The revenue stream is hampered every time a claim is denied that leads to lost payment. This can significantly impact the cash flow of an organization that is important for the stability of any medical practice or facility.
Now why is denial management important?
First, denials need additional administrative work for rectification that consumes staff time and resources. These resources could have been used for other high value tasks. The cost of reworking a claim, including staff labor, can be huge. In some cases, the cost of rectifying a denial in medical billing may even exceed the claim’s value.
Second, a high denial rate reflects issues in your billing process. Some common issues include coding errors, insufficient documentation, or failure in verifying patient eligibility. The systematic problem can lead to claim denials signifying potential compliance risks and inefficiencies which could be costly in the long run.
Also, frequent denials can damage relationships with the payers. Regular claim resubmission might raise red flags for your practice which can lead to investigations, audits, and hefty fines.
Challenges Leading to Medical Billing Denials
Let's explore some major reasons behind denials in medical billing.
No Prior Authorization
One of the most common causes of denials in medical billing is lack of prior authorization. This happens when healthcare providers do not get pre-approval from the insurance company for any specific procedure before providing it to the patient.
Insurance companies generally have a list of services that need prior authorization. Not following the procedure will definitely result in payment refusal or denied claim!
Eligibility Verification Errors
Eligibility verification issues come up when there is a mismatch regarding the patient’s insurance coverage. These issues can happen when the patient’s insurance plan does not cover the provided service. This might also happen if the healthcare provider is unaware of changes in the patient’s insurance status.
Inaccurate coverage verification might lead to claims being mistakenly sent to the wrong carrier. Sometimes the patients themselves are confused between Part C plan and a Medicare secondary plan that covers the costs associated with traditional Medicare A and B plans.
Coding Errors
Coding inaccuracies are the most common type of denials. This involves the use of outdated or incomplete coding of medical procedures and diagnoses. The healthcare industry relies on complex coding systems like ICD-10. Errors can happen easily while translating a patient’s diagnosis and the services provided to these standardized codes.
Even the smallest error can lead the claim towards denial as it may not accurately reflect the patient’s condition, or the services provided.
Inaccurate Modifiers
Incorrect use of modifiers can lead to rejections and denials in medical billing. Modifiers are used to give additional information about a procedure like if it was performed multiple times or if it was more complex than normal.
In the case of inaccurate modifiers, it can create discrepancies in the claim which leads to denials. This happens because a modifier can significantly alter the meaning and context of a code.
Timely Application Submission
Timely Submission of claims play an important role in maintaining the healthcare revenue cycle management. If the claim is submitted after the deadline set by the insurance company is over, it will surely be denied.
The specific timeframe for timely filing ranges between 45-365 days, depending on the insurance payer’s policy. A healthy practice is to fulfill the requirements as soon as possible. Late submissions indicate a lapse in your process and will result in lost or delayed revenue.
Strategies to Prevent Denials in Medical Billing
Analyzing and Prioritizing Current Denials
A comprehensive analysis of existing denials is the foundation for identifying and addressing repeating billing issues. It needs a detailed review of denial patterns, categorizing them by reasons like coding error, lack of authorization, or patient eligibility issues.
By prioritizing denials based on frequency and financial impact, a healthcare provider can focus on the most important areas. Providers can also implement regular analytics processes like monthly reviews, which helps keep track of the effectiveness of corrective actions. The strategies can be adjusted on the go.
Leverage Technology
Technology plays a crucial role in streamlining your billing process and reducing human errors. Healthcare providers can always invest in technology to handle repetitive administrative tasks like real-time eligibility verification.
Moreover, partnering with specialized billing services or consultants can provide access to the resources that you might be lacking.
Staff Engagement and Training
The staff plays a very important role in minimizing the billing errors. This is why regular training of staff is essential to keep the staff up to date about the latest billing guidelines. They must be updated about any changes in guidelines, coding changes or regulatory requirements.
Regular workshops work best to train your staff while maintaining a high level of proficiency and engagement. Real life scenarios can also be included in the module which enhances the practical aspects of complicated billing issues.
Coding with Maximum Efficiency
Accurate and precise coding is important for medical billing. Making sure that the coding process includes all the nuances of each patient encounter decreases the likelihood of denials. Regular audits of coding practices help identify the common mistakes and areas of improvement. Providing coders with the most up to date coding knowledge and regular education on guidelines ensures that the coding signifies the latest industry trends.
Why Do You Need Medical Billing Services in Texas?
Medical billing is the most important aspect of any healthcare organization when business is considered. If you are a healthcare provider in Texas, the complexities are too hard to handle. This is where medical billing services in Texas can help you.
Professional medical billing companies can take care of all your documentation requirements, which gives practitioners time to focus more on patient care. It is understandable that medical billing and coding can be very exhausting to manage for a medical practice. They already have a lot on their plate to manage and medical coding simply adds to their responsibilities. This takes up a huge amount of time and resources and even then, there is no guarantee of accurate reimbursement.
Unify Healthcare Services is one such medical billing company that takes your revenue to a whole different level. We have a team of professional coders who are well-versed in all the elements of medical billing and coding. We can take care of all your administrative tasks so that you can focus on your sole specialty.
Our team is always updated about the latest medical billing and coding guidelines along with compliance and regulatory requirements. This is how we ensure accurate claim submission and adequate reimbursement for your practice.
Unify Healthcare practice believes that every healthcare practice must be reimbursed for every treatment they offer to their patients.
We do not offer just medical billing services; we offer mental peace.
