How Medical Billing Services Offer Professional Denial Management?

Submitting clean medical claims reduces account receivables, accelerates reimbursements, and guarantees financial stability. The process is lengthy, so we cannot take it lightly at any cost. That is why most medical practices outsource billing and coding to professional medical billing services to avoid claim denials.

So, Where Does the Error Happen?

When we look deep into the data, we can see denied claims, most of the time, simply have minor issues. These issues can be avoided with just careful consideration and professional assistance.

Studies suggest that more than sixty-five percent of claims miss information as minor as social security number or a person’s middle name. These issues seem minor but can get a claim denied.

Healthcare service providers and hospitals cannot afford such negligence because it dents their financial situation. In the worst instances, claim increase beyond the permissible window for claim submission or resubmission, resulting in lost revenue opportunities.

Healthcare Industry Promotes Effective Denial Management

A medical billing company relies on data accuracy but understands that things can happen. However, they weigh the need for smooth claims towards staffing and monetary resources from time to time.

There are sensible steps that you could take to improve your chances of getting your claims paid. It all starts with accurate patient data, which is important for smooth billing and coding process.

This article takes you into several techniques that billing companies use to increase clean claims.

Wait! A Lot Goes Behind a Clean Claim

Many healthcare organizations use a clearinghouse to test healthcare eligibility before sending out claims to payers or after the claim denial.

There, the claim is “scrubbed” for accuracy: policy number, prognosis codes, demographic records, and insurance standards. If the claim makes it through the approval/correction stage, preferably the payer accepts, processes, and pays the claim. Unfortunately, this state does not happen as smoothly as described, and mostly there is a considerable threat to healthcare organizations. We can easily avoid this from happening.

But, first, start with the top reasons why claims get denied.

Top Reasons for Denied Medical Claim

Denials occur for a number of motives.

Some are related to eligibility criteria, issuer enrollment, or the patient’s plan.

According to a poll conducted in December 2020 by the Medical Group Management Association (MGMA):

· 42% of healthcare leaders stated prior authorization as the top motive for denials in their organization

· 29% of healthcare leaders stated demographic problems as the top motive for denials in their organization

· 7% of healthcare leaders blamed late data submissions as the top motive for denials in their organization

Other reasons that are blamed for denied claims are errors in CPT codes, payer requirement inconsistencies, medical necessity requirements, and lacking data/documentation.

Payers are known for their complex rules, and claim rejections are based on that. For instance, with COVID-19, hospitals had visibly refused acute patients who required emergency treatments for the fear of going bankrupt. They did not have enough resources to cater to COVID-positive and other patients simultaneously. Also, insurance companies didn’t pay for elective treatments for a fair amount of time. It led to high denied claims recently.

Moving forward, one of the biggest challenges medical billing and coding services face is getting payers to know people are stuck invalid emergencies most of the time.

In an otherwise case, if a patient’s plan doesn’t meet the criteria for the diagnosis, the claim is denied.

Thus, you can never know what error can root the cause for a denied claim. Professional billing companies have to go through every information in detail to avoid any inconvenience.

Here are the strategies to help avoid claim rejections.

Strategies to Avoid Claim Denials

Denials are frustrating, but there are actions billing organizations can take to boom their claim acceptance rate.

Get the Accurate Data: Validate the patient’s contact records and verify demographics at the prior stages of medical billing.

Get Prior Authorization Upfront: Determine compensation requirements for documentation, medical records, and other statistics via a transparent data transmission system.

Look into Insurance Details: Professional medical billing services usually look into copayments, deductibles, and other insurance details.

Conduct Risk Analysis: Determine all matters, which can pose any threat to the claim compilation or reimbursement.

Verify Health Benefits: Check what services are patients liable for and to what extent payers can reimburse for the rendered service.

Conclusion

Medical billing companies have a huge responsibility to deal with the administrative burden on behalf of clinicians. And, honestly, they have been doing it exceptionally well. Times have changed, and rules have been stricter. We cannot blame payers for being inflexible about payment matters.

However, what we can do is outsource medical billing services to a company near us for a streamlined process to prevent any leakage in the financial bucket.

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