medical claims - MED-Miles LLC

Most common Medical Claim Denials

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.

Missing Information

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

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.

Coding Errors

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;

Unbundling:

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.

Upcoding:

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:

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.

Why Med-Miles?

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.

Improve Your Medical Claims Billing Process in 8 Simple Steps

Medical billing claims are very extensive and complex processes. Making improvements and tracking the effectiveness of these steps helps in a smooth billing process.

As it is a very long process the probability of errors is much higher. The medical claim billing process involves preparing the data of the patient, processing it, coding, submitting a claim, tracking denials, and submitting a claim.

There are some of the steps involved in the process. Let’s read them below!

Medical Claims Billing Process Steps

1. Maintain Patients Records:

For a successful medical claim, the first step is to maintain patient records effectively. The records must be updated and managed well, any kind of error or mismanagement may create a negative impact on claiming.

A patient record may consist of his name, address. Age, demographic, and his insurance-providing company. Make sure you communicate well with patients as better communication helps to collect accurate information.

2. Negotiate About Financial Responsibility:

The second step is to ask the patient about the details of his/her insurance provider. See all the details of the insurance contract and figure out which services are included and which treatment and services are excluded.

Tell the patient about the insurance agreement earlier, guide him about which treatment will be paid by the insurance company and which services are excluded from the insurance agreement and the patient has to pay for it.

3. Keep Away From Duplicate Billing:

During the billing process, it has been seen that duplicate billing arises more often, which makes this process more complicated. With the extensive amount of data, it might be possible that a double-entry might be generated. So it’s good to have a close look at patients’ records to avoid these kinds of errors.

4. Automate Your Billing Services:

An automated billing process can help in reducing time and enhance the chances of positive returns.

Automation assists the workers to maintain and enter the records more accurately and allow them to focus on other important things.

5. Improve Coding:

Proper coding is an essential element for a successful claim. It helps the insurance provider to find out what kind of treatment is acquired by the patient.

Make sure the use of correct CPT & HCPCS provides additional information about the services the patient received during his/her stay in the hospital.

It is very essential to set up proper coding which enhances the chances of getting paid by the insurance company abruptly.

6. Monitor Denial Management:

Tracking denials are a very common and tedious process, it is the part that can impede the whole billing process. Commonly there are some reasons behind it, like improper coding, lack of experience by the workers, and insufficient documentation.

Denials may also occur when the claim is not submitted at the due time, it may make the process of billing even longer, as some insurance companies only approve the claim when they are submitted on time.

Another reason for denials is the wrong documentation. In this scenario, there are possibilities that both the sites filled their documents wrong. It might be the fault of the insurance company as they missed something in the document or maybe the fault of the claimer who somehow didn’t make the documents properly.

It’s good to have checks and balances when you are constantly receiving denial rates, by monitoring the denial rates you can easily figure out the things to make your billing process smooth. There are few steps that could low the denial rates. As most of the denial rates occur due to faulty documentation, the proper training of the workers helps in some ways.

Sending daily charts by the health worker to the billing department is the one process that makes things even clearer and easy. Coding could be made better by adopting that practice.

If still, the denials rates are not decreasing then a short review of your daily billing process activities can help to deal with it.

7. Hire An Outside Billing Management Firm:

Outsourcing the team of experts who manage your billing process is a great way to get rid of many of the problems. Working with a team of experts will free health workers from doing the complex process of billing so they may be more focused on managing patient treatment.

Outsourcing can help to maximize your cash flow better because they have a team that assists you to make proper management of your revenues with fewer denials.

With extensive support and excellent relationships, The Mediators have a track record of 100% customer satisfaction. From daily quality assured claim submission to daily denial management monitoring to immediate payment posting with no sign-up cost.

8. Assure The Quality:

For an effective billing process, one must assure good quality, as revenue is at stake so ensuring good quality is a must-do thing. You can simply assure the quality by maintaining a patient log in which all the essential details related to the patients must be added, like his/her name, address, treatment, account number, pending dues, etc.

Taking a close look at the pending amount and comparing the data with prior records and making a quality estimation for its proper management.

The healthcare industry is drastically changing and it is estimated that new trends could replace the traditional setup. To cope up with the changing technologies one must be able to forecast and make constant changes in his strategy.

Quality assurance is a need to get effective results, nowadays the billing process is assisted by EHR & EMR, Termed as the Electronically generated health records of the patient. It makes the claim more effective and easy. The good working quality of these frameworks assured better claim management.

Want To Improve Your Billing Process Today?

If you are tired of managing your billing process and still not able to get desired outcomes. Don’t worry. Med-Miles LLC is here for you. Our vision is to provide a smooth billing process with maximum profitability. Feel free to call us at (888) 598-9181 for further information.

How To Overcome Challenges In Medical Claims Processing?

Risk has become an inherent part of the healthcare service industry as a small change can ruin your practice reputation and revenue which can eventually lead to failure.

At the healthcare business, managing thousands of medical claims can be a daunting task for healthcare providers because each claim requires a diverse approach and standard procedures on its own. Which makes it difficult for insurers to render improvements in claims operations.

Throughout especially in busy times, the number of transactions and associated patient and payer data can overwhelm your billing department.

The National Health Insurer Report Card written by the American Medical Association has said a 2% growth in claim-processing errors could cause disproportionate administrative expenses of about $ 1.5 billion into the medical systems.

For this reason, the claims process needs to be managed differently in order to ensure that the value provided to patients is paid properly, both in terms of accuracy and timeliness.

It doesn’t matter where your studies or travel will take you, a good insurance plan can only be assessed by the way they process and pay for insurance claims.

Let’s suppose that your claim doesn’t not quite as smooth as you expected. What if you moved into a hospital and now you receive threatening letters from insurance companies in regards to your payment? Or, what if the claim process went smoothly, but your claims were refused? To find out the answers to these questions sit tight and continue reading.

Here in this blog, we will look at medical claims processing challenges and how to tackle them as quickly and correctly.

Changes In The Norms and Rules Of The Government

It’s observed that changes from the rules and regulations of the country have a substantial effect on the medical claims processing. The policy differs in every nation, and it’ll influence customer care.

Changes in the healthcare industry usually take place at the legislative level, but once adopted, they have a direct impact on facilities and resource use.

For example, the way patients and administrators use resources such as Medicare and Medicaid has changed with the adoption of legislation. Technology has further influenced the way health care administrators handle resources and manage health centers.

Because of this, it might be challenging for the insurance industry to effortlessly handle the claims processing as a way to raise productivity and customer satisfaction, despite the changes happening.

Documentation Process

Managing a huge volume of documents can be complex and time consuming for the healthcare industry.

To be insured against a healthcare treatment, being a claimant you will have to provide several documents, which will have to be checked by the insurance companies before your claim is approved.

Therefore, such a time-consuming process may in return slow down the processing of insurance claims, which sometimes leads to disappointment in case of your claim rejection.

Incorrect claims result in rejection and as a claimant, you consider submitting the claim is a waste of time and useless and end up losing your potential revenue. Thus, you can see how inefficiency can lead to loss of revenue.

Chances Of Insurance Fraud

It is possible that with a large volume of documents to process or having a lot of work pressure, there might be errors in processing insurance claims.

Therefore, if the documents submitted are not verified or investigated then it could be a con. It is also observed that to speed up the process, at times, many insurance companies pay the amount to the wrong person.

Thus, you can see how for the insurance industry it can be difficult to solve the problem and detect fraud.

How To Simplify The Process Of Medical Claims?

You have experienced how the high quality of services for customer satisfaction has become mandatory for healthcare companies.

Now among the best ways to increase your revenue efficiency being a practitioner, you should consider outsourcing for your medical claims, medical billing, claim rejection, medical audit, or even for your revenue cycle management.

Outsourcing your medical billing will help you in saving up your precious time and the most important thing you will be able to increase your revenue.

MED-MILES LLC can help to streamline the data processing aspect and ensure efficient claim processing to increase your revenue.

You would be considering why Med-Miles for outsourcing? Our team at Med-Miles strives to maximize your revenue while handling all the important tasks including timely Claim Submission, Payment posting, Denial Management, AR, Patient Services, Reporting, and Analysis, and many more.

How Can Outsourcing Benefits You?

By outsourcing your medical billing solutions, you can access useful benefits that will boost your workflow and increase your profitability. Few benefits include:

You can gain a better competitive advantage and ultimately this will lead to your practice career success.

It reduces your time and money and can help you to focus more on your core responsibilities instead of managing a large volume of documents.

With outsourcing, there is no need to invest in infrastructure, equipment, and resources.

You Won’t have to train the in-house staff or hire someone to take care of claims processing.
Your insurance claims processing services will be efficient and productive also giving rise to greater customer care.
Outsourcing will lower your administrative costs and error rates and ensure health care providers remain compliant and maintain optimal levels of patient service.
Last but not the least, outsourcing medical billing helps you in building your healthcare practice.

Bottom Line

From here you can see that while claims processing services are difficult, their solution can be simple, especially if you outsource to an efficient and reliable service provider that follows these tips to ensure a high-quality service. Outsourcing will not only help you in building your healthcare practice reputation but can also help you in boosting your revenue. Med-Miles is a perfect way to outsource your healthcare practice.

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