How to Prevent Denials

Preventing denials is really pretty simple – send clean claims.  You can never be in such a rush to get claims out that you don’t take the time to check each one for accuracy before you transmit or print them.  Taking the time to proof claims saves more time than it would take to process the denial and send it back out.

Preparing to send clean claims starts at the beginning of the patient experience.  Are you getting all the patient and insurance information you need to process the claim?  Simple things like not having the correct date of birth for the patient or the insurance subscriber, not putting in the sex of the patient, the right zip code, doctor NPI number or the correct member number are just some of the reasons for claims to deny on the spot.

Many billing programs have a “pre-billing edit” function that can be run before claims are processed.  This report will give you a list of all claims not ready for submission which allows you to fix them and then send.  But you can also be denied on submission by your clearing house for some different reasons like the claim is coded for workers comp or auto and cannot be sent electronically and for many reasons stated above if not caught on the pre-billing edit.  Both reports work hand in hand.

By the time the claim gets to the insurance provider we are hoping for 100% clean claims.  If they are denied it could be for a members ID# not being recognized or that the insurance has been terminated, there is no current authorization or referral or other related issues. 

If you look at all the listed denials, it is evident that almost all can be avoided with accurate patient intake and patient data entry. Employing highly efficient processes with check points to insure that correct data is collected and followed up on will dramatically cut and/or eliminate the most denials. If denials are not caught on the pre-billing edit reports, first electronic submission or from the insurance provider you may get a denial in the mail or on an electronic EOB.  These need to be addressed immediately and rebilled or called on. 

A few things to note - when you get a denial, fix it so that it will not occur again.  This may mean you have to go to other claims for that patient and other patients with the same insurance and make changes.  Any denial that represents a specific way the carrier wants claims to be submitted must be addressed so that no claims for that insurance are returned for the same reason.  Too often denials are not taken care of to eliminate further denials for the same reason.

Let’s take a look at some other things to look at when entering charges and submitting claims that will avoid denials, returned claims or reasons for audits.

1.      Do you have the right patient?

2.      Are the charges – procedures/modalities – correct for that patient?

3.      Have you charged the right amount of units for each code?

4.      Are you charging for the right diagnosis?

5.      Does the documentation support the charges?

6.      Do the charges support the overall treatment time for Medicare patients?

7.      Does the documentation support the plan-of-care and the short and long term goals?

8.      Did the patient have an authorization or referral in place at time of service? 

These are just some of the things both the clinical and administrative staff needs to keep in mind when charging for services.  The more you can do prior to claims being submitted will help to avoid denials and insure payment for services rendered.  Make sure your staff is well trained and held accountable for the claims submitted and denials received.  A good training and development program is worth the time and money for all new employees as well as a refresher for current employees. 

 

Diane McCutcheon, President

DM Business Management Consulting Services, Inc.

Account Matters – Billing & Collection Services

4 Charlesview Road, Suite 4

Hopedale, MA 01747

P: 508-422-0231  F:  508-422-0234

diane@dmbmcsi.com