Operant Billing Solutions is an industry leader helping a wide range of medical and therapeutic practices to streamline their revenue flow through our time-tested medical billing best practices. We strive to help each practice we work with to help reduce their insurance accounts receivable by getting claims paid quickly and efficiently. This allows each of our clients to focus on patient care and eventually expanding their own practice. All while taking the stress of medical billing off your shoulders.
Medical claim denials and rejections are a major, and all too common problem facing nearly all medical practices. Reducing them and managing rejections and denials is a great first step toward streamlining your revenue flow. It’s important to note that there is a significant difference between a “Claim Denial” and a “Claim Rejection.”
Understanding Claim Rejections
Most claim rejections are related to formatting issues or insufficient data. They are more common with Medicaid and Medicare applications, though medical insurance companies can also reject claims. With claim rejections, the policy or the claim itself was not entered into the system and thus can’t be processed in order to pay the practitioner who is providing the services.
With most claim rejections, the errors or missing data simply need to be entered correctly and the claims process will usually proceed normally. While there might be some delay, the practitioner will eventually be paid for services rendered. At Operant Billing Solutions, our industry best practices applied to the medical billing process helps reduce the chances of a rejected claim or a delayed claim payment.
Understanding Claim Denials
Claim denials differ from claim rejections in that the claim itself was processed correctly and received by the insurance company, government agency, or other institution, but still received a negative determination. In a scenario like this, the claim can rarely be resubmitted without some new grounds applied for an appeal. This process usually starts with a reconsideration request. If you skip this step the claim will likely be denied again and yet more time will be lost.
What Are The Most Common Reasons Why Claims Are Denied?
There are several reasons why a claim might be denied. This includes things like:
Insufficient Coverage
Not all policies are the same. It is possible that certain treatments or therapy techniques simply are not covered under that individual’s policy. In a situation like this, a change in coverage or plan might prevent a future claim denial, though you, the service provider, likely will not see a payment from the insurance company or other institution for services rendered. Ideally, this issue should be caught when scheduling and verifying information.
Missing Information
Some forms are lengthy and complex. Something like a single data field left blank or filled out incorrectly can lead to the claim being denied by the payer. This could be something as simple as a coding error, empty data field, or a missing social security number. In a scenario like this, you might simply need to correct the error or input the missing information for the claim to be processed by the payer. Claim denials like this tend to be more common with solo practitioners who are attempting to handle 100% of their billing and administrative tasks, while still trying to treat patients.
Duplicate Service Claims
Sometimes the same claim is accidentally submitted twice. This is usually “red-flagged” in the payer’s system due to the same date, same provider, or same encounter. Sometimes this is a clerical error. If corrected the claim will be paid promptly.
Service Adjudicated
The service or benefit for the claim might already be included in a different coverage bundle. In some situations, the funds were included in a different claim creation period.
Filing Expiration
Many payers have a set number of days allowed to file a claim. For most this is within 30-days of the services being rendered. If the claim isn’t filed during this sometimes-narrow window, the claim will be denied. Filing expirations are rarely an issue when working with an outsourced medical billing firm like Operant Billing Solutions.
Reducing Claim Rejections and Denial Rates
Some things can be done in-house to help reduce the number of claim rejections and claim denials your practice encounters. Though it does require additional time invested by your existing management or administrative staff.
The first step starts with staff education and making sure that everyone involved in submitting, filing, and coding a claim knows how to handle denials and rejections. Next, you can start by setting up routine chart audits and spot-checking for data issues or documentation quality issues. This also helps to potentially identify patterns that might be slowing the claims process.
It can also help to set up automated payment systems for external vendors. Not only does this help to optimize claim management practices but it can also help to catch potential denials before they are entered into the system. Though, again, you are going to need oversight from management or your in-house administrative staff.
Conclusion
Claim rejections and claim denials can certainly hamper your ability to effectively treat a maximum volume of patients as well as impede your natural revenue flow. Delays and inconsistencies in the revenue stream can also lead to other trickle-down problems that hamper your ability to treat patients and ultimately slow the growth of your practice.
Allocating additional time and resources to management or other administrative staff might be an effective short-term solution. Though it’s rarely a good option for solo practitioners or practices with an already limited staff.
This is where Operant Billing Solutions can help. We don’t use cookie-cutter software, instead, we use industry best practices to make sure all your medical billing needs are taken care of efficiently. Our staff are experienced and highly trained to be able to spot and address potential problems in order to reduce the number of rejected or denied claims that your practice experiences.
This leaves you more time to treat patients and expand your practice, while also freeing up your in-house administrative staff to focus on more productive duties. All the while, making your practice’s revenue stream more consistent and efficient.
