How Does Smart Billing Reduce Claim Denials?

To reduce claim denials, introduce smarter medical billing by automating eligibility checks, accurate and current coding, clean claim technology, denial trends analysis, and preauthorization workflow streamlining in order to limit claim denials. Active and evidence-based billing helps decrease mistakes and make the best use of reimbursements.

The issue of denial of claims in the current medical environment is no longer just a transient setback, but an enormous loss to medical facility institutions, in terms of finances. Existing data suggest that denials of claims can go as high as 20, much of which is avoidable (American Medical Association). Technology- and workflow-assisted smarter medical billing practices can decrease such denials by a huge margin leading to quicker reimbursements and better revenue cycle management (RCM).

Here in this blog, we will simple down actionable ideas to decrease claim denials, optimize reimbursements, and use smart solutions that can revolutionize their health care practice or organization.

What are medical claim denials?

Before getting into the solutions, it is important to get to know what claim denial is.

Claim denial occurs when an insurance firm denies a request of a provider or patient to pay on healthcare services provided. Rejections may be either hard (permanent and irreversible) and soft (corrected and re-submitted). The most common denial causes can consist of:

• Incomplete or wrong patient data
• Unacceptable medical codes
• Eligibility problems
• No preauthorization
• Backdating of filing

 

The Claim Denial Effect on Finances

Healthcare providers are losing millions of dollars through claim denials. In addition to loss of direct revenue, it may cost more than 25 dollars to rework each claim. Throw in staff time, resubmissions, delayed payment and patient dissatisfaction, and the cost is high.

Fast Stats:

• More than 65 percent of denied claims are not submitted again.
• Almost 90 percent of denials are avoidable.
• The denials that practices spend more than 20 percent of the revenue cycle time.

Instead of merely reducing these kinds of risks, smarter billing maximizes operational efficiency and cash flow.

The Reason Why Smarter Medical Billing Is the Answer

Outsourcing or the blind automation convention is not the only thing referred to as smarter medical billing. It alludes to information-based, pre-emptive as well as behavioral strategies that reduce human error, improve transparency and exploit technology smartly. How, then, can we employ smarter billing practice in order to minimize claim denials?

Top Strategies to Reduce Claim Denials with Smarter Medical Billing

1. Run Rugged Eligibility Check

One of the commonest and most preventable reasons of claims denials concerns eligibility. Such matters normally occur when providing services to patients whose insurance policies may not be active, have not fulfilled their deductibles, or whose benefit has not been covered, and this makes it either denied as long as the claim has been been put forward. To prevent this, it is critical that a rigorous (or a "rugged") eligibility check be done prior to every appointment(s) or procedure. An effective eligibility checking process validates the insurance coverage of the patient, what the insurance covers, the co-pay to be paid and the need to authorize the process in real time. Automating the process and making it a part of the front-desk functions will make the claims dependent on the current and up-to-date coverage data, effectively minimizing the risk of claims being rejected and the payments being delayed.

Better Billing Tip:

• View real-time eligibility checks as a part of your practice management system.
• Train the front desk employees on how to update insurance data on each visit.
• Take advantage of automation applications calling out outdated or inaccurate policy.

2. Uniform and Automate the Data Punching Operations

Mistakes in the demographic data of the patient are one of the primary causes of automatic denials of claims (names misspelled, misreported insurance information, lack of a policy number). Such errors are normally caused by manual data input systems, particularly when this is completed through time urgency or separated systems. To minimize such mistakes, which occur due to human error, healthcare facilities ought to automate and make standardized the recording of data (or data punching). With the help of automation technology such as those available in electronic health records (EHR) and practice management systems, front-office personnel can make sure that there is accuracy, consistency, and completeness of patient data at the source since first point of contact. Not only does this reduce denials, but it also increases the general effectiveness of the revenue cycle.

Smarter Billing Tip:

• Less manual work has been achieved by utilizing pre-filled forms and electronic health records (EHRs).
• Check-in data: scan and cross check data with the scanning tools or insurance card OCR (optical character recognition).
• Carry out periodical audits so as to rectify the frequently made data input errors.

3. The Clean Claim Technology is to be used

One of the best strategies in minimizing denials and speeding up reimbursement is by making clean claims. A clean claim is the claim which does not contain any mistakes and has all details needed to process the claim by the payer without manual work. Conversely, claims that have any problem at all, even minor (missing fields, wrong codes or wrong formatting), will tend to cause rejections or delay of payment. Clean claim technology takes advantage of automation and real time verification to make sure that all claims are patient specific before they come to the payer. With the help of this technology in your billing process, you can close a rather substantial gap in first-pass acceptance rates, and cut the administrative rework.

Smarter Billing Tip:

• Invest in charging software that does the validation of the codes, modifiers and mandatory fields in real time.
• With the help of machine-learning equipped instruments which, on the basis of previous denials, can be used to avoid them in the future by highlighting close patterns.
• Institute pre submission of claim scrubbing to inherent and rectify problems before sending to the payer.

4. Be Accurate and keep Up-to-Date Coding

Successful claims processing is based on the accuracy and up to date medical coding. Among the most common causes of claim rejection and most preventable are errors in CPT, ICD-10, or HCPCS codes, cases when codes do not match. The smallest differences may translate into rejections, late payments, or risk of non-compliance. Given the fact that coding guidelines and policies of various types of payers change regularly, providers and billing departments have to be up-to-date and attentive. According to DD, keeping the accuracy of coding does not only avoid denial of claims, but also makes reimbursement efforts precise and helps in minimizing chances of audit.

Smarter Billing Tip:

• Have trained medical coders or collaborate with coding professionals who are well versed with the nuances of a given specialty.
• Remain up to date with new releases of codes and payer particular guidelines every year.
• Use coding systems with assistance templates that make the most suitable code suggestions of documentation.

5. Automate Preauthorization Process Workflows

Prior authorization is a requirement of a payer to perform or prescribe a specific procedure(s), medication(s) or service(s) before the service is provided or prescribed. This ought to be a part of cost containment and assure medical necessity but it usually ends up being a major and critical point of delay in billing processes, and result in delayed care, burdens of workload to administrative staff and as well as denial rates when incorrectly done. Preauthorization In healthcare, automation of the preauthorization workflow can enable organizations to streamline approvals and decrease manual errors and payer-specific rule requirements causing delay in turnaround time and claim rejection.

Smarter Billing Tip:

• Automate preauthorization checks by using your built-in workflows in your EHR or your RCM software.
• Install alertation of services that usually need authentication.
• Follow up the responses of preauthorization electronically in order to reduce delay.

6. Control and Analyze Trends of Denial

The issue of why claims are denied is one of the most effective actions that any healthcare organization can consider, and it will be very helpful to obtain a clear and comprehensive picture of its causes. Too many times, the current practices take denials as the unique instances and not the awareness of the trends or the core causes that provoke them. Such an ad hoc attitude results in repetitive errors, lost money, and unneeded paperwork.

Leading the change to a proactive approach with a view to data analysis, there will be a possibility to identify the pattern, to eliminate systemic errors, and to introduce a more intelligent approach to the billing process, therefore eliminating denials by a large margin in the future.

Smarter Billing Tip:

• Monitor the key denial metrics (e.g., denial rates by payer, service type or provider) using analytics dashboards.
• Find out about the repetitive problems and deal with them at their source (e.g.: re-education of personnel, new protocols in documentation).
• Conduct denial management meetings and trend review on a monthly basis assigning corrections

How to Train Staff for Smarter Billing

There is no such a thing as people and processes. To mitigate denials without an effective technology is impossible without well-trained staff.

• Conduct Billing compliance and payer status quarterly workshops.
• Train billing, front office and clinicals on each other to develop responsibility.
• Teaching using real case studies and denial examples.
• Offer the possibility to access online learning and education certifications (e.g., AAPC, AHIMA).

When Is the Right Time to Outsource Your Medical Billing?

In-house management of medical billing may prove even harder, particularly as it gets compounded with a rise in the number of claims, alterations in payer guidelines, and a heightened administrative load. When your claim denial rate is above 10 percent consistently or when your internal billing department just cannot meet the load between the limited number of resources or lack of training or old systems, it is time to think about the possibility of outsourcing the medical bills to a professional medical billing agency.

Advantages of medical outsourcing are:

• Quality billing companies have reputable billing vendors with qualified professionals who have a lot of knowledge in ICD-10, CPT, HCPCS, and payer-specific coding rules. Their experience decreases the risks of coding mistakes and raises clean claims.
• Best-in-class billing companies leverage denial and prevention and resolution techniques that are aided through analytics and workflow processes and guidance focused on minimizing rejections and accelerating reimbursement.
• Outsourcing is less expensive since it spares the overhead expenses of recruiting, training and maintaining billing employees. Outsourced teams can grow with you as your practice expands, and they also will not compromise performance.
• It is also simpler to work with a team that only does billing and reimbursement processes to meet the ever-changing insurance and regulatory requirements.

Conclusion

Preventing claim denial is more than being reactive to mistakes, now it is forward looking and data-dependent. With advanced billing technology, proper coder, streamlined processes, and yearlong education of employees, healthcare providers will be able to make fewer claims, less rework, and will be able to increase their cash flow. Assessment of denial patterns and system performance on a regular basis maintains a healthy revenue cycle that is flexible. Eventually, smarter medical billing is not all about the increased revenue but about the reliable, scalable system that will support smoother patient experience and better care.

As claim denials become an increasingly insidious threat to profits and regulatory compliance levels, now is the last time to make posting under your control. In case you want qualified assistance, you may turn to Onemed Billing, a trusted RCM company that can facilitate your billing to lower denials and maximize reimbursements with personalized end-to-end solutions of RCM.