Claim denials cost providers millions of dollars each year; hard-earned money that could be allocated to more deserving services. We find that many practices do not have the time or resources to work through these denials and therefore those charges are written off and the practice loses out on revenue. The good news is we’re here to help mitigate that lost revenue, which starts by identifying what those common denials are.
Service Not Covered
These are words a provider never wants to hear but is a common denial that practices often receive. This denial occurs when the service is rendered prior to verifying the patient’s benefits and cross-referencing those benefits with the payer’s LCDs (Local Coverage Documents / Determinations) and Articles. These documents outline whether or not a particular item or service is covered on an intermediary or carrier-wide basis. Additionally, each governmental payer and private health plan do not share the same policies and also do not necessarily publish those guidelines where they are easily accessible. With a little extra time and research as well as implementing a process that will keep everyone up-to-date with the ever-changing guidelines, practices can easily avoid such a denial.
If a claim lacks even the slightest piece of pertinent information, you’ll find yourself with a denial. These denials can range from missing data in the fundamental fields such as date of birth, address, policy number, date of the accident or admission, lack of explanation of benefits from the primary payer, as well as failing to code to the highest level of specificity. These denials can be avoided by utilizing smart software that verifies all the information necessary to a claim prior to it being submitted to the payer.
Providers are not trained to be coders so why is it that they pay the price for coding errors? Payers expect all submitted charges to have been scrubbed appropriately and follow all coding guidelines. Minor errors such as an ICD-10 code with too few digits, services that fail to include all applicable codes, and codes that do not align with the correct place of service can all trigger a denial from the payer. The idea of memorizing coding guidelines sounds like one more laborious task but leveraging a coding team and integrating National Correct Coding Initiative (NCCI) triggers within your practice's software provides a proactive approach in preventing these denials.
Duplicate Claim or Service
A service that is resubmitted for an encounter on the same date, by the same provider, for the same beneficiary, or for the same service will be denied as a duplicate. Sounds reasonable enough but the key to these denials is determining if the charge is in fact a duplicate claim or if the intent was to submit a corrected claim for another denial. It’s easy to disregard a duplicate denial as it suggests that the claim has already been adjudicated but you’ll find yourself leaving money on the table if you do not closely monitor these denials for accuracy. Each payer has particular protocols for which they are willing to accept corrected claims. If you fail to follow these guidelines, it will result in a denial for a duplicate claim in addition to the original denial. You’ll want to be sure that the true denial is addressed accordingly and you have received payment before you file away the duplicate denial.
Limit For Timely Filing Has Expired
Each denial that you receive will ultimately result in a payment turnaround lag. It also can lead to a lack of payment if not addressed within a timely manner. By ensuring you submit your claims within the payer’s timely filing guidelines, you can easily avoid this denial. That sounds simple enough but it would also require you to be aware of every single one of those guidelines. Unfortunately, there is not a universal policy and can vary from payer to payer. Some accept charges up to 365 days from the date of service and others as little as 90 days post-service date. Submitting claims electronically can help expedite your submission and also provide you with acknowledgment reports should you find yourself having to produce supporting documentation that the claim was filed within the payer’s requirements.
Additional Ways to Prevent Denials
Let’s face it, some denials are inevitable. Why not leverage the denials that you’ve already received to create predictive logic in your software that can flag potential denials in the future. By analyzing denial trends and also collecting supporting documentation in advance, you can eliminate denials altogether!
Once you have identified the denial trend and implemented a process to avoid future denials, take it to the next level. After you have established that your documentation has substantiated your historical billing, initiate a contract with the payer to eliminate future requirements to have to provide supporting medical records. An expert team can help support that negotiation and also facilitate the management of tracking, analyzing, and reporting on these trends to get ahead of them.
With all that said, how do medical denials impact your patients? Your top priority is maintaining a good relationship with your patients, and you can still do so while preventing revenue loss. It helps to have an expert on your side that is conversant with the provisions of these payers. They can navigate those denials, advocate on behalf of the patient, and alleviate the burden on both the patient and the practice.
Our experienced team of experts is here to support you through all these challenges. Let us take on reducing your claim denials and increasing your practice revenue so that you can focus on what truly matters most - your patients.
To find out more about pMD's suite of products, which includes our charge capture and MIPS registry, billing services, telehealth, secure messaging, clinical communication, and care navigation software and services, please contact pMD.