CLAIM DENIALS: WHY DENIALS ARE ON THE RISE POST-COVID.

 

Claim Denials are far too common, and they continue to grow post-covid.

There are multiple factors that can cause an increase of denials. However, the most frustrating part about them, is that ~90% of current claim denials are preventable!

Yes, 90% ARE PREVENTABLE!

 

THE RUNDOWN:

Let’s jump right into your weekly rundown and start by identifying some common reasons Why these preventable claims are occurring in todays’ practices.

• High turn-over in medical staff
• Missing Information
• Medical Necessity
• Services not covered by the payer
• Expired limit for filing
• No Prior Authorization
• Unable to maintain consistent follow-up

 

WHY IS THIS IMPORTANT?

High turn-over in Medical Staff

Who isn’t dealing with high turnover in their practices right now? It is so unfortunate to hear this from our clients on the daily basis. There are so many offices that are struggling to hire and keep quality staff to help their practice function. This is a contributing factor that is leading to increase billing denials due to the reasons we will break down a little later.

This is also why more providers are partnering with us to work together and alleviate the stress of hiring, managing, and maintaining their revenue cycle management in house. We work as an extension of your practice, so you can focus on patient care and the overall patient experience.

Missing Information

Payers are really focusing in on missing information which will often automatically trigger a denial if any field is accidentally left blank.  We review every claim, insuring they include all required details from patient demographics, accurate insurance information, precise CPT and ICD-10 codes, authorization codes, accurate modifiers, and practice details.

Paying attention to these details and having a protocol in place is associated with a decrease of an estimated 60% of medical billing denials

Medical Necessity

“Medical Necessity” or “Medically Necessary” are terms that the insurance companies have implemented to determine if a health care service provided by a practitioner is reasonable, necessary and/or appropriate based on evidence-based clinical standards of care.

Many insurance companies have published some kind of “Medical Policy” or “Clinical Guidelines” to outline what they will consider appropriate for certain treatments or procedures. These guidelines update often and randomly throughout the year. We review these publications regularly to ensure that all our clients are up to date on what is required by each insurance company to cover a procedure.

Services not covered by the payer

Often this will occur when your staff isn’t checking with your patient’s insurer to confirm the procedure and the services being rendered are covered under their current benefit plan.  Insurance changes are frequent, difficult to keep up with, and often confusing for patients to understand. This is where it is beneficial to have a protocol in place for your staff to call and check prior to scheduling the procedure. By adding this step, you are going to be able to provide your patients with important information regarding their specific coverage and what to expect if they may have any out-of-pocket expense so they can prepare.

I cannot tell you how many times I have heard from our clients how surprised they are to find patients willing to pay their out-of-pocket portions prior to procedure when they know about it and have time to prepare. So, you are not only improving your patients overall experience in care within your office, but you are also streamlining your revenue in preventing denials, increasing probability of collecting payments from patients which is win for everyone.

 

Expired limit for filing

This topic seems to be the most surprising for practitioners to hear. Payers have a very strict time frame to file claims. Also, there is often a specific deadline to submit corrected claims or to appeal claims. If you or your staff find that you are not submitting claims before the deadline, they WILL be denied.

This may sound easy, right? Submit before the deadline or else it will be denied. That is true, however, payers can make things difficult to keep up with changes and protocol for their deadlines. It is often surprising to hear that there are multiple deadlines for each stage or specific to procedures, etc. Again, navigating the waters post covid only adds to the confusion. At one point, they were accepting appeals and at least considering paying a portion for claims submitted after deadline but that is not always the case. The best advice I can propose is, do not take that chance.

This is especially important for providers working out of an ASC or OBL. If you have any modifications or additional codes that need to be added to a claim, you want to make sure you are aware of the payer’s timelines to get this addressed correctly, or you are at risk of denial without the possibility of an appeal.

No Prior Authorization

Knowing if you need to obtain a prior authorization or precertification can be tricky and confusing depending on the insurance plan. As part of our Verification of Benefits process, we detail what codes require prior approval and where to obtain the appropriate authorizations specific to that patients plan. Most insurance companies have opted out of allowing retro-authorizations for procedures that require it. Many insurance contracts also will not allow a provider to hold a patient responsible for services that are not covered for this denial reason. This is a crucial process for every office to ensure they are not doing procedures for free.

Unable to maintain consistent follow-up

When your staff is running full throttle and tending to your patients, as they should, opens your practice to the possibility of a high percentage of preventable claim denials.

PREVENTION IS KEY!

Again, we are talking about mistakes that are leading to an estimated 90% of preventable medical claim denials.

By bringing your attention to these common mistakes, you now have to knowledge to identify the areas of focus to help implement a plan, develop a protocol within your practice to prevent this loss of revenue from continuing in your practice.

 

If you have additional questions on the systems and protocols that we implement into our clients’ practices, submit a request on our website and we will reach out. Or call us directly at 855-936-6023.