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Regardless of how great your frontline staff is, claim denials are an unfortunate part of the medical billing terrain.  Medical coding and billing is a complicated field, but steps can be taken to streamline the process and reduce the number of claim denials.

If we take a look at the “Usual Suspects” of the top ten claim denials we can see where to course correct.

Denial ReasonDetailsOrigination
1.     Incorrect Patient Identifier InfoWhat techniques are your teams using to capture or verify information? (asking or telling)Before services
2.     Coverage TerminatedWhen are your teams verifying coverage?Before services
3.     Requires Prior AuthorizationDo the services provided match the authorization? Are ABNs obtained? Was the plan information captured correctly?Before services
4.     Services excluded or not coveredWhat tools are you using to track plans and their covered services?Before services
5.     Request for medical recordsWhat flags are in place to allow records to go out with the original claim? Are you addressing this issue with the plan at negotiation time?Before services
6.     Coordination of BenefitsWhat techniques are your teams using to capture or verify information (asking or telling)? When are your teams verifying coverage?Before services
7.     Bill liability carrierHow your teams are asking questions about the visit can reveal potential liability carrier coverage.Before services
8.     Missing or incorrect CPT codesWhat tools are you using to track trends in your coding by service, provider, system setup or coding specialist?After services
9.     Timely filingHave you built in plan specific deadlines?After services
10.  No referral on fileWhat tools or flags does your system provide to alert staff to these during the scheduling process?Before services

As you can see eight of the 10 denial reasons listed above could or should be handled before services are rendered. There are a myriad of reasons as to why there is not a “slam dunk” fix to this age old problem. All the more reason to choose an EHR system that works with your teams to provide alerts, as well as analytical reporting before and after services are rendered. Getting the right information after the fact can help you help your teams identify and correct those that “got away.”

Do you have all the systems in place, but are still experiencing the same denials? You may have great teams doing great work but not yielding great results. Having the time to go back and see what is or isn’t working to ensure adjustments are made and revenue is realized is usually a luxury your teams don’t have due to time and staffing constraints. Have you considered partnering with a third party to optimize your processes and services?

Optimum Healthcare IT’s Revenue Cycle experts are accomplished at reviewing denial patterns, scheduling and registration processes, claim edit patterns and more. Once we have completed the diagnosis, our team, in coordination with your teams, will provide a plan of action. We want to partner with you to manage and maintain sustained results to allow your team to realize the fruits of their labor. Click here to learn more.

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