Methods to Reduce Medical Claim Denials

  • March 01, 2021

  • One of the most troubling problems in many medical practices today is without a doubt, medical claim denials.

    You have to be proactive in developing strategies to improve operations and their Revenue Cycle Management (RCM). Complicated approval processes and requirements that differ by health insurance plan make claims management very challenging for even the most well-informed medical practices.

    A Proactive Plan Can Help in Reducing Denials

    Review your practice operations can help identify where you’re meeting and/or exceeding financial expectations and what systems could use improvement. To guarantee an authentic evaluation, it may be beneficial for your practice to engage a third-party RCM vendor to perform the audit.

    Collect Accurate Insurance Information

    Enter precise data into the Electronic Medical Billing System. It’s essential to ensure factual and verified patient information is collected and utilized, such as:

    • Subscriber or patient’s full name correctly spelled.
    • Accurate primary and secondary insurance information.
    • Correct DOB.

    Insurance verification should be verified prior to each visit, including the following:
    • Coverage has not been terminated.
    • Services that might not be covered.
    • Type of Coverage.
    • Co-pays and Co-insurance.
    • Deductibles remaining.

    When possible, obtain prior authorization approval and accurately document it before the patient’s visit. This process can take between one and three days to complete.

    It would be very beneficial to your practice by using advanced automation software that uses artificial intelligence (AI) and machine learning capabilities to proactively manage your prior authorizations in real-time.

    Document Referrals

    Confirm that referrals from a referring provider are documented prior to the patient’s visit and not cause for rejection when the claim is submitted.

    Liability or Work Related Injury

    Determine if it is a liability or work-related injury so that you can properly guide the patient in their course of action. The following types of insurances may take precedence and will change your handling of the situation (and the claim):

    • Worker’s Comp
    • Motor Vehicle
    • Business Liability
    • Homeowner’s Insurance

    Proper Documentation

    This should be part of the patient visit and should be completed in a timely manner. Narrative descriptions carry more weight than checklists with insurance companies.

    Ensure that you have verified the following:

    • Establish which insurance plan is primary and which is secondary?
    • Avoid duplicate claims which lead to overpayments.

    Timeliness in Filing

    This is an issue that can cause a claim to be rejected. With most insurance carriers, the limit is 90 days or beyond. While that may sound like more than enough time, all the reasons above can cause a claim to be rejected or denied for timely filing, which is further evidence that a proactive plan can decrease denials and increase the bottom line.

    Develop a Multi-Prong Approach

    This can help ensure that claims acceptance rates improve. To start, a review of rejected claims can help develop steps to achieve denial prevention. Following are some strategic questions that should be asked as part of this review:

    • Does your medical practice have an accountable RCM system with strong oversight and training for new and existing personnel?
    • What bottom-line improvements could be actualized utilizing a revenue cycle partner to manage the RCM?
    • Would the practice benefit from improving technology?

    Ensure proactive coding for the procedures performed during the patient’s visit to eliminate missing or invalid information.

    To learn more about how RevPro Healthcare Solutions medical billing services can help you make more money, limit overhead expenses, and make your practice more efficient, contact us below or call us at 561-578-8400.