by Sherri Dement
Denied claims have a major impact on your practice. Yet, they are often ignored because staff does not have time to address the denial, the knowledge to understand the denial remark code, or how to correct the denial. Today, reimbursements are decreasing while the cost of running practice is increasing, making it crucial to correct denied claims immediately.
Avoiding denied claims by filing a clean claim every time is the key to creating a more stable cash flow. With that being said, who are you trusting to set the course for the successful processing of a clean claim in your practice? If you have been removed from this process in your practice, you might not have a confident understanding of the claim denial rate in your practice.
The process begins when the appointment is scheduled
It is important to realize that the responsibility of creating a clean claim is not dependent on one person in your practice. The process begins with the scheduler. The scheduler should be detail oriented especially when collecting the patient’s name (no nicknames when filing insurance), DOB, and the complete Insurance ID to include the prefix or suffix, if applicable. If your patient is not the subscriber to the medical plan you will also need the name and DOB of the subscriber. Additionally, you will want to obtain both the vision and medical plan information at this time. Information must be exact in order to obtain a verification of benefits.
Once the verification is in hand you can review and compare the actual plan name, subscriber and patient information, the patient’s benefits, etc. If discrepancies are found (the patient no longer has coverage, the practice is out of network, or they don’t have coverage for specific services) you have time to contact the patient and resolve the issue over the phone. You will create a more positive experience for the patient by taking care of this before they are standing before you with a reception area filled with patients.
Review and confirm insurance information at check in
At the time of check-in staff must review the information entered in the PMS by the scheduler, confirm the information has been entered correctly and if not, correct the errors. There are instances where the scheduler has obtained correct and current information on the call, but at the time of check-in a staff member changed the information because a copy of the card from a previous insurance they found was saved in the system. It’s always best practice at check-in to ask for the card, make a copy, and verify all information entered is current.
Staff will sometimes say, “It is uncomfortable to ask a patient for their insurance information.” This is an indication that you do not have the appropriate person in this position or they need additional training. If the patient is not willing to provide insurance or vision plan information, then your staff can politely inform them that the visit will be considered “cash pay” and they will be responsible for paying the “prompt pay discount” at the time services are rendered. It is impossible to verify benefits or file a clean claim without current insurance information. At any doctor’s appointment patients are expected to present insurance cards and all pertinent information required for the practice. Your practice should not function any differently.
If the claim is denied and you have not obtained a copy of the card it has now become even more difficult to collect for services rendered. Without it, you are unable to verify the patient ID, subscriber ID, or the correct Payer ID (required for an electronic claim submission), and you will not have access to the exact 800# to discuss the denial with a representative. Also, without a copy of the card your staff will not know if this is a PPO, an HMO plan, or if they are out-of-network. Most plans will not allow you to collect from the patient for this denial because it is the responsibility of the practice to know what plans the practice is participating in and to know and understand in and out of network benefits before the patient is seen.
Chief complaint drives the exam
Once the patient is in the room, there are more details of importance in order to create a clean claim. What is the purpose of the patient’s visit? What did they tell the scheduler? The chief complaint drives the exam. It is imperative to know the reason for the visit before information is entered in the PMS. Is this going to be a medical exam or vision check? Per the review of your verification of benefits, what services are covered in the patient’s benefit package? Will the patient need special testing? Is a precertification or authorization required? If so, do you have one? What CPT will you be billing? Will your documentation support the medical necessity for the CPT? Are you familiar with Local Coverage Determination (LCD)? Have you reviewed the LCD and do you have the appropriate diagnosis that warrants this procedure? Does the test require a CLIA number? Have you input the CLIA in the PMS so that it will appear on the HCFA? Have you chosen the correct provider and do you have their correct NPI? Who has the final review over all data before the claim is submitted for processing? These are all questions that need to be considered during every appointment.
You’ll never get it 100% right, but strive to get close
While it is always the goal to have a claim process through upon the first submission there is still a chance the claim will be denied. Payer denials will vary from invalid CPT, invalid diagnosis code, or a combination of the two. Another denial often seen is due to frequency which means the payer determines that the information provided does not justify the number or frequency of services billed. Managing rejections and denials is a time consuming process, and will take time away from your staff doing other important tasks, or goes ignored and leaves money on the table.
I would like to leave you with the following questions, and if you are unsure of your answers, contact us and we can dig deeper with you.
- What is your protocol for addressing denied claims?
- Are you confident you have the right person for this job and they have full knowledge of how to handle denied claims?
- What is your current clean claims rate?
- Is your staff working to correct denied claims and resubmit them as quickly as possible?
- Is your staff correcting the reason for denial or are they just submitting the claim repeatedly, as is, thus creating more denials until the claim times out?
- Is your staff writing off balances rather than researching for an accurate CPT and/or diagnosis code? (Staff should not have the power to adjust off balances). The provider treating the patient will make that decision. If you have ordered a test or procedure your documentation must prove and support the medical necessity for the test or procedure).
Need help determining if you are set up for claim filing success in your practice? Contact us for a free consultation to discuss your challenges.