Medical claim denials are very common for Health care service providers. For every practice, the higher denials rates can be very harmful to their operations and can damage their revenue cycle management system.
In order to get all the revenues from the insurance payer, your practice needs to reduce all the common errors which can lead to claim denials.
In this article, we will discuss some of the most common reasons behind a claim denial and some tips which can help you to reduce them effectively in order to increase your revenue stream.
Common Billing Mistakes That Lead To Medical Claim Denials
To successfully avoid the medical claim denial we need to figure out some of the most common mistakes that occur in the medical billing process. Following are the Common billing errors that can lead to claim denials.
The health care service provider submits the claim to the insurance company to get the reimbursement. In this process, they are required to submit all the essential information of the patient so that they can easily get the payment from the Payer.
Any missing or false information can mislead the insurance company and you may suffer from a claim denied. It is the responsibility of the health care service provided that they provide all the essential information correctly to the payer.
When a patient came for the services the hospital front desk officer should carefully note all the essential details of the patient which include his name, address, social security number, contact information, and his insurance service provider.
Verification of Insurance Coverage
It has been seen that many times the patient is unaware of their insurance coverage plans.
Insurance companies cover some specific treatment plans for the patients and there are multiple treatments and procedures that were excluded from the insurance coverage plan and many of the claims are denied due to those reasons.
It is the responsibility of the healthcare system to check and verify the insurance coverage of the patient. And initially tell them that there are some treatment plans which are not in the coverage of your insurance plan so you need to pay for them by yourself. So a prior Authorization is essential for effective RCM.
Duplicate billing is another Common reason behind higher medical claim denial.
It happens when your practice resubmits the claim instead of following up.
Late Claim Submission
Late claim submission is also associated with a higher claim denial ratio. Many health insurances approved only those claims that are submitted on time. If somehow your health care practice failed to submit the claim in the required time slot then you can lose your revenues.
Having In-Experienced Staff Members
The chances of errors have significantly increased when you are working with an inexperienced staff member. Many of the health care service providers particularly those who are operating their Billing activity with an in-house team usually face this kind of problem.
Many Healthcare service providers have lack of resources to hire experienced team members so they somehow rely on their in-house team members.
On the other hand, if any medical practice is utilizing their in-house staff then they are required to give them proper training to handle all the Billing activity. Because an inexperienced team can’t handle the billing operation as effectively as the experienced staff members.
In-Experienced staff members enhance the chances of having high medical claim denial. Coding errors are supposed to link with an inexperienced worker while it could have occurred with an experienced worker too because it is one of the most complex activities in the whole medical billing process. Some of the most common coding errors which will lead to a higher claim denial are;
This type of coding error occurs when we use multiple codes for a single medical process or activity. While this Medical procedure can be covered by utilizing a single procedure code. It is considered one of the most common coding errors. It can also be considered a fraudulent activity if someone did that intentionally.
It is also considered a clear violation of a false claim act if someone did that intentionally. In this type of coding, the health care service provider uses inaccurate billing codes to get higher reimbursement.
Under coding is exactly the opposite of upcoding; many health care service providers can get rid of auditing if they are doing this intentionally. As it is considered an activity to get rid of auditing but in many cases, it happens due to not knowing the exact use of appropriate codes.
This coding can lead to a medical claim denial in which a health care practice can lose a significant amount of revenues and some legal actions were also taken against them if somehow they were found to be doing those acts intentionally.
Steps To Reduce Medical Claim Denials
Many of the health care service providers rarely focused on the exact reason behind the higher medical claim denial ratios. Below are some tips to reduce the medical claim denials.
- Get existing data to find out what kind of denies your practice is receiving more frequently.
- Also, you have to monitor the clean claim ratio. By monitoring the clean claim ratio you can better get feedback. All you need to do is to make a quick comparison between a denied claim and a clean claim and make your Billing team aware of what they are doing right and where is the margin to improve.
- Build an experienced team of workers for this purpose you have to hire some experienced workers. If your practice has a lack of resources then you can give effective training to your present staff members to ensure a better Billing activity.
- Use appropriate billing software which will enhance the productivity of your team member and you will surely see better results.
- You can also outsource your Billing activity from a Billing services providing company. They are experts in giving a better service regarding the management of RCM.
As outsourcing is one of the best ways to increase the chances of getting a higher reimbursement. Many health care service providers effectively manage their medical claim denials with the help of our services. We have been serving our clients for more than 8 years.
Our expert services assure you maximum reimbursement with a low ratio of claim denials as we are fully aware of some of the most common reasons behind higher medical claim denial rates. You can call us at 8885 989 181 to get more information.