Denial prevention is important!
We are used to hearing these words frequently. As shifting towards claims denial management to prevention can take your profitability to the highest standards and vice versa. But what about the payments that you have lost so far? Sometimes healthcare providers may neglect the importance of some task, from where they can drive the maximum revenue. For example, the efficient management of denied or rejected medical claims.
It has been estimated that the majority of the laboratory practitioners lose significant revenue due to the inefficient management of rejected claims. Sometimes, healthcare providers don’t use their right of appeal & lose the compensations permanently. Imagine! How it can be frustrating not to get what you’re owed. The same is true for healthcare businesses. Laboratory practitioners find it disturbing to lose the reimbursements, despite delivering the standard medical aid to the patients. So, along with the implementation of claim denial prevention strategies, what’s even more crucial? The answer is obvious. It is appeals processing!
This process is undoubtedly complicated and requires a considerable amount of time. But when it is being handled efficiently, it can bring enormous profits and add value to your revenue cycle management. You just need to play the cards right & have a complete understanding of how to appeal the medical claims successfully. Before further discussions, it’s pertinent to shed a light on the factors that hinder the reimbursements from the insurance companies.
What Is a Health Insurance Denial?
Claim denial occurs when insurance companies refuse to cover the cost of the medication or treatment due to certain reasons. There are the following reasons that can hold lab technicians back from getting reimbursements:
Medical coding isn’t specific enough. Coding errors occur when coders fail to accurately translate treatments, patients’ diagonals, and medical services into standard codes.
- Medical claims don’t contain complete information i.e. date of the accident, injury, medical emergency, and date of onset.
- Incorrect modifiers.
- Failure to submit the claims in the given time window of the payers.
- Invalid insurance information.
- Lack of prior authorization.
- Insufficient medical necessity.
- Incorrect patient’s demographic information.
- Duplicate billing.
How Can You Appeal a Rejected Claim?
Ways to mitigate the billing errors, proactive tips to prevent claims denials, etc. The majority of the lab technicians usually read about stuff like that. But have you ever dive deeply into the discussion regarding the successful claims appealing? Of course not! However, if you are looking for innovative ways to open your denied claims for reimbursements efficiently. Then don’t look further. In this article, we have tried to cover all the aspects related to the resubmission of rejected claims. With the implementation of the right solutions, you can save your laboratory business from sinking. Here are the following tips you can utilize to make your appeal process effective.
1. An Appeal Letter is Important
Some healthcare providers often commit the mistake of not sending an appeal letter to the payers. They usually prefer to send only a balance bill along with an explanation of benefits (EOB) to the insurance companies. Therefore, you must write a concise appeal letter to increase the worth of your request. In this way, healthcare providers can easily explain their request for what they wanted to have reviewed, i.e. coding denials or fees. Though writing an appeal letter will take a little more effort, it can make a huge difference to the profitability of your lab business. Once you have decided to send an appeal letter. Here’s a question that arises: how can you prepare a letter or which things need to be added to the letter? For the convenience of our readers, I am going to share tips that can help you to design your own.
- Complete name, date of birth, address and the insurance identification number of the patient, whose claim was rejected. Additionally, you should also mention the date of healthcare service provided to the patients.
- Make sure that the opening sentence of the letter clearly describes the fact that you are appealing the claim denial.
- The body text of the letter must contain the reasons for denials, steps that you have taken to rectify the errors. And why the medical bills should be paid.
- In the concluding paragraph, you should demand reimbursements, supported by the necessary documentation. Now you can send this letter along with supporting documents.
2. Ensure If Claims are Corrected
As we have already discussed the factors that can result in claim denials. So, it is the responsibility of your denial management staff to closely review denied claims to perform root cause analysis. After knowing the key reasons, they should rectify the errors & make proper adjustments according to the instructions of the payers. Before sending an appeal to the insurance agencies, make sure that claims are being thoroughly analysed, & mistakes have been eliminated.
Double-checking of claims for CPT coding, documentation, diagnoses, and EOB is very important. Because, if healthcare providers again submit the erroneous claim, then the appeal will not drive positive outcomes. Along with checking the above-mentioned errors. It’s crucial to take a close look at modifiers to ensure that they’ve been appropriately describing the changes in medical procedures. The use of incorrect modifiers to manipulate reimbursements can also result in accusations of abuse or fraudulent activities. In order to save your healthcare practice from financial as well as legal troubles in the future. It’s significant to make a note of the problem, in case there is a coding error like unbundling, upcoding, undercoding, etc. And review it with the entire billing and coding staff to prevent such occurrence in the future. Because having a history of such coding errors can result in federal penalties, imprisonments, cancellation of licences, heavy fines, etc.
3. Comply With the Medical Record Documentation
The golden rule of thumb for successful medical billing and coding is: to claim payments for the medical services or procedures, only what you can describe with the documents. Before reaching out to the payers for reimbursements. It’s the responsibility of the billing staff to review the documents and medical claims to make sure that all procedures that were reported were actually performed.
The best thing you can do is a careful analysis of the doctors’ notes. Such as: from the beginning to the end of the medical procedures and all in between. In this way, you can get a better understanding of the reportable procedures. Those were performed and not mentioned in the note summary. Moreover, to ensure the accuracy and the high specificity in reporting the healthcare services rendered. Laboratory practitioners must review the medical documentation to ensure they are reporting the right codes.
4. Resubmit the Claims & Follow up
We all know the fact that every insurance company has its own time limits for the resubmission of claims too. Denied claims that surpass the filing limits, would lose the chance of getting reimbursed permanently. As a result, healthcare practitioners will never collect their hard-earned revenue. Hence once you have made the required rectifications, then the next step is the resubmission of denied claims before reaching the deadlines. After submission, it’s very important for the billing staff to regularly follow up with the insurance companies. They should stay connected with the payers until laboratory practitioners get maximum revenue back in their accounts.
Prevent Future Denials
No doubt, a major percentage of denied claims is recoverable. But reworking on a denied claim increases the financial & administrative burden of the healthcare providers. Because it has been estimated that reworking on a claim costs approximately 25$. Just think about the burden associated while dealing with a claims backlog. Therefore in order to avoid such inconvenience, healthcare providers should implement smart lab billing solutions. That can help them to shift their attitude towards claims denial management to prevention. Here are the following tips that can help you in keeping your denial rate minimal as much as possible.
- Always stay on top of the changes in industry regulations, payers policies, medical billing, and coding guidelines.
- Make sure that your administrative staff undergoes constant training.
- If you are using orthodox and inefficient methods to prepare and process the medical claims. Then you should immediately stop doing that. Because such methods always leave a huge room for error and can slow down your lab revenue collections management. You should use cutting-edge technology to upgrade your billing system to a more effective one.
- Hand over the complicated billing and coding tasks to the experts, having extensive experience in managing the medical claims efficiently.
- Outsource medical billing and coding services to a professional and well-experienced billing collection agency. In this way, you don’t need to invest time and money in building an in-house RCM department. You just need to pay a fixed amount and in return, you will get the assistance of the industry experts. Outsourcing results in improved billing collections reduced administrative burden and streamlined cash flow.
If you are looking for professional billing assistance, then Laboratory Billings is here to help you. It is the most sought-after destination for healthcare providers across the United States. Our billing and coding experts provide customized lab billing services to address all your financial needs.