Health care services and medical practices are all about caring for the patients and helping them retrieve their health. However, just like all businesses, a medical practice also needs to make enough revenues to manage smooth and effortless operations.
The major portion of the revenues of the medical practice comes from the medical insurance claims that are submitted to the insurance companies. But, it has often been seen that due to the denial of medical claims most practices lose out on a large amount of revenue. This can have a serious backlash on revenue generation. That’s why experts believe that all medical practices should have a flawless denial management strategy.
Handling denied insurance claims can be a frustrating, time-consuming, and complicated process for practitioners and administrative staff. When you outsource insurance claims processing services, you need to collaborate with a skilled insurance claims processing company that has an optimal mix of people with state-of-art technology to provide highly efficient and reliable insurance claims.
The average claim denial rate in the healthcare industry is 5-10%, and about two-thirds of denials are recoverable. Below we will discuss common claim denial management struggles and 6 tips for handling Insurance Claim Denials Management to keep the claim denial rate below 5% and boost unhealthy cash flow.
Tips for handling insurance Claim Denials
Some basic strategies for resolving claims denials that can save practitioners time and improve their practice’s cash flow are outlined below:
Review all notifications regarding the claim thoroughly
The most important step in claims processing is to review all notifications carefully. When you receive remittance advice, explanation of benefits, or other notification from an insurance company regarding a claim.
The notification should specify whether the claim was paid in full, partially paid, delayed, or denied. Follow the carrier’s instructions for resubmitting the claim along with any missing or corrected information if the claim is determined to be “unclean” or contested.
In case the claim is partially paid or if payment is denied, the notification should specify the reason and outline the specific procedures and documentation required to resubmit the claim or file an appeal.
Call the carrier immediately for more information if the notification is not clear. In addition to eliciting a stated reason for denying a claim, you may find out that the claim was adjudicated incorrectly because of an administrative error on the part of the payer. You might also discover that your submission procedures do not match the company’s requirements but that you can make some simple adjustments to your procedures to streamline future claims submissions.
If you believe that resubmitted claim denial was improper, you may appeal the decision according to the carrier’s instructions. Keep in mind that appeal procedures may vary by the insurance company and state law so make sure that you know the exact information you need to submit with your appeal.
The appeal should comprise an explanation of your reassessment request, along with required supporting documentation such as:
- a copy of the claim in question
- copies of earlier communication to the company about the matter
In case your claim is denied on the grounds of “medical necessity,” you may need to submit further information to prove the necessity. Be aware that it is crucial to meet your obligations under the HIPAA to protect psychotherapy notes and to provide only the “minimum necessary” information.
You may need to resubmit the claim or file an appeal more than once to reverse a company’s decision, but don’t give up. Your persistence can indicate to the insurance company that you are serious about resolving the issue.
It is crucial to submit and resubmit claims timely, within the timeframe clearly defined by the company or the laws of your state. Otherwise, the claim may be arbitrated based only on the information you already provided.
Get to know the appeals process
While submitting an appeal, make sure you are familiar with the company’s appeals process. When you know the policies, you can respond to the carrier’s actions in a better way. Stay updated regarding the claims adjudication and appeal processes for each carrier with whom you work. Companies often include this information on their websites and, provide hard copies of the information each time you sign a new contract with them.
Maintain records on disputed claims
When you call an insurance company for more information about a claim, it is important to keep a record of the information you are provided with, along with the name of the representative with whom you spoke. Save the information with other key information about the claim, including:
- why the claim was partially paid
- delayed, or denied
- the actions your office took to follow up on the claim
- and the outcome
These records can be helpful in future actions such as:
- taking your appeal to higher levels
- submitting complaints to the state insurance commissioner
- pursuing subsequent litigation.
- The records can also serve as a helpful file of sample appeals letters and documentation that can aid your office in avoiding or resolving future claims denials
Remember that help is available
Claims denials handling can be a frustrating process, but it can save time and money for you in the long run by alerting you to the expectations and requirements of the insurance company you contract with. You can reduce the occurrence of rejections and denials in the future by ensuring that your billing procedures are consistent with the company’s requirements. However, if you still encounter reimbursement problems with a particular insurance company, contact your state insurance commissioner’s office for help.
If you want help in driving the whole process smoothly then zee medical billing can provide end-to-end support and deliver with sharing and implementing our knowledge of the process.
Get a free no-sting attached billing services quote from ZEE Medical Billing for your practice.