The Right Medical Denial Management Strategy

There have been changes in the payment methodology, and with the Affordable Care Act (ACA), we are witnessing a paradigm shift in the healthcare landscape. Unfortunately, despite the patient-centric care model and value-based services being at the core of this new development, the healthcare industry loses about $262 billion in claim medical denial out of $3 trillion. This figure translates into each provider denying $5 million on an average. The right medical denial management

Strategy can help you to ensure no medical denials:

But the biggest thought is “Why are these figures important?”

When such figures are so massive in a claim medical denial, it won’t be far-fetched to think you can get denied by the provider. Unfortunately, it means you will be losing the revenue like hundreds of other practices despite rendering the services.

However, there are ways to combat claim medical denial with a proper medical denial management strategy. As a practice, you need to be proactive instead of reactive when it comes to medical claims management.

The right strategy can help you with the following and ensure few to no medical denials:

A solution at the beginning

Did you know? A part of the medical denial management system ensures that your staff are registering the patients with the right details required for getting the 100% reimbursement. It will include the gathering of all the correct details that your practice would need to file the claim for your services.

Ensure meeting the deadlines

When the right medical denial management strategy is in place, an accurate system will automatically be developed as a part of your medical billing process that will maximize your practice workflow’s efficiency. It includes keeping the entire paperwork ready and submitting the medical claims on time. In fact, one of the common causes that lead to claim medical denials is missing the claim submission deadline.

Understanding the claim medical denials

Even when you have everything right with all the correct information, there can be instances when your medical claims are denied. Therefore, a part of the medical denial management strategy wants you to understand the root causes of the medical denials instead of just assuming its reason. Such a medical denial analysis will help you further to predict any future rejections under similar circumstances and mitigate them as soon as it arises.

Stopping the claim pile-ups

It is quite easy to lose track of the medical claims denied in the manual system, letting them to pile up. In fact, it can quite be a difficult job for a practice like you to keep a track of the loss of such revenue due to claim pile-ups. All thanks to an automated claim management system software that can be put in place to keep an accurate track of the denied medical claims and consequences arising income. It will help you to streamline the medical denials and undertaking of the resubmission process to help in mitigating the revenue loss.

Improves the revenue collection

A proper claim medical denial management strategy can help in boosting the overall revenue collection of your practice. In addition, the automated streamlining medical billing and coding process will help you to improve the workflow, and the resubmission of the medical claims denied while keeping a track of those that your practice fails to collect timely from the insurance providers. Thus, it helps your practice to maintain its profitability level.

Identifying the issues

With the automation medical claims management system software and analytics, you can quickly check daily analysis reports. This will help your practice to identify any issue related to medical claims at the earliest and take care of it immediately before such a claim medical denial-related problem escalates. Moreover, it also allows you to identify the areas in your practice that can cause revenue loss.

Keeping up with changes

As we all know that medical billing rules and regulations are constantly changing, and you must keep up with such trends. In fact, one of the inherent reasons that lead to claim medical denials is the failure to stay abreast with these changes. Again, all thanks to the right medical denial management strategy as it can immediately notify you about the changes happening in the medical billing and coding landscape so you can implement them. In addition, the automated claim software can be updated with such new developments to file the medical claims accordingly.

Despite the complex system of claim lodging that often leads to claim medical denials, it can be prevented with the right medical denial management strategies. Such a process starts with knowing the reasons for the claim medical denials, thereby training the practice staff to ensure that it does not happen again. Though you can do the entire process in-house, it doesn’t guarantee complete success keeping in mind the time, efforts, and money involved. That’s why it is usually recommended to take the help of a professional medical billing and coding company known for implementing a full-proof claim medical denial management system into the practice. You can Ajust Solutions for helping you in putting the right claim management strategy in place for your practice.

More Info Click Here: Appeal Medical Claim

How Does a Health Insurance Claim Work?

 Many factors decide what your medical claims process will look like. It could involve mailing documents, calling a representative, using the company's app, or a combination of these actions.

Your medical claims process depends on how much you have to pay before your provider does, called the "deductible." You pay your deductible, and your provider pays the rest of the claim. If you need to find your basic coverage, look for the declaration page of your basic healthcare policy to find it.

Your claims process will also depend on the type of claim you are submitting. Medical claims can become lengthy processes. You may have meetings with adjusters, get approvals for estimates. The process for health insurance can differ in that it often takes place without your involvement.

If you feel that your provider has not been fair with your medical claim insurance policy, you have the right to file a complaint with your state health insurance commissioner.

Best Practices to Combat Medical Denials

When it comes to effective medical denials management, knowledge is the key. To gain and act on that information, several best practices can be applied to stay organized and informed on the root causes and reasons.

Know the stats: Knowing initial medical denial, dollar, and the claims rates leads to an understanding of the reasons for high denial charges and opens new chances to improve processes and reduce or eliminate problems.

Keep the process organized: Losing track of denied claims will make you lose money, and climbing denial rates will lead to some serious issues like bankruptcy. Thus, implement a prepared denial management procedure that leverages HIPAA-accredited tools and technologies to track submitted claims.

Identify trends: Quantify and categorize medical denials by tracking, evaluating, and recording the trends. Emphasize data and analytics to help identify and rectify the issues causing medical denials in the first place, reaching out to physicians and payers for assistance as appropriate and tapping the expertise of Patients’ advocates to help reduce medical denials and improve compliance.

Act quickly: Follow a validated process to get medical denials corrected, preferably within a week, a goal that is possible when an established workflow is in place to track claims as they enter and leave the system.

Establish a team: Classify the available resources from all sections and leverage their know-how to put in place answers and to track and report developments, which will, in turn, set up standards, reduce backlogs, and help classify root causes. This robust team of experts would include key members from admitting/registration, case management, patient financial services, nursing, health information management (HIM), information technology (IT), finance, compliance, and, of course, the physicians.

Collaborate with payers: Payers also benefit from resolving denial issues, so a payer-provider collaboration can help in addressing them more efficiently, which will also help achieve system efficiency more rapidly.

Quality over quantity: The best way to exploit limited resources and time is to follow up with the medical claims that are already addressed, which will help simplify more quality claims rather than a higher number of lower-quality claims that do not yield anything.

Track progress: Monitoring progress will help differentiate between areas that are doing well and those that aren’t while allowing for analysis and improving system efficacy. This helps your organization know which areas are doing well and which need improvement. Consider automating medical denial management processes, which also frees more time to rework the refusals.

Conduct presentation audits: These should include audits of payment advice reviews, write-off adjustments, zero payment claims, registration, and insurance verification excellence.

Verify patient information: Leverage patient portals that update patient information and take time to verify that information and the patient’s insurance coverage—while keeping the billing team updated about the policies and educating staff to improve data quality.

Learn from previous rejections: Indecorously established data can be cause for claim rejection, so leverage data including healthcare insurance company and payer ID lists available in electronic health records (EHRs). Tracking and analyzing rejection and denial trends helps differentiate between them, making it easier to learn where problems occurred and fix them quickly.

Meet deadlines: Failing to follow deadlines established by healthcare insurance company policies can affect claim filing.

Know the clearinghouse: From assisting with insurance companies to providing detailed explanations for rejection, maintaining a solid relationship with the clearinghouse will improve processes and benefit both groups.

Understand claim formats: Many healthcare billing companies use EHR solutions to submit medical claims using a standardized format, which can make it easier to identify and resolve problems with denied claims. Claims are often submitted in ANSI837, and information of this allows one to apply ANSI loops and segment references, which is more efficient than sifting through HCFA1500.12

Conduct regular follow-ups: Track every claim so medical denials and rejections can be corrected and resubmitted on a scheduled appeal, preventing revenue loss.

Follow a decision tree approach: A decision tree forces consideration of all possible outcomes and traces each path to a conclusion. This approach helps in training staff to address medical denials more effectively.

Lastly, some organizations might reflect supplementing internal medical billing and coding operations with outsourced medical services. Through outsourced services, organizations can rapidly gain access to a team of highly trained and accomplished professionals who dedicate their time to interacting with insurance companies and understanding the reasons behind rejections and medical denials. Investing in the support of outsourced medical services can also allow interior teams more time to concentrate on other features of maintenance and patient experience.

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Medical Denial - What Papers Do I Need?

Keep copies of all information related to your claim and the denial. This includes information your health insurance company offers to you and information you offer to your insurance company like:

 

• The Explanation of Benefits forms or letters showing what payment were denied
• A copy of the application for an internal appeal that you sent to your health insurance company
• Any documents with extra information you sent to the health insurance company (like a letter or other information from your physician)
• A copy of any letter or form you are required to authorize, if you select to have your doctor or anyone else file a request for you.
• Notes and dates from any phone calls you have with your health insurance company or your doctor that relate to your request. Include the day, time, name, and title of the individual you talked to and details about the discussion.
• Keep original documents and submit copies to your health insurance company. You will need to send your health insurance company the original appeal for an internal appeal and your request to have a third party (like your physician) file your internal appeal for you. Make sure to keep your own copies of these medical documents.

More Info: How to Fight an Insurance Claim Denial

Six Reasons Why Your Medical Claims Are Denied

There are many factors that drive the increase of claim denials in the Healthcare sector. Whether the provider or payer is at fault, it is understandable that denials occur because of how complex the medical coding and billing system is. Providers must work closely with their in-house or outsourced medical coding professionals to ensure patient information is documented accurately and medical claims are filed on time.  

Poor management of processing medical claims can negatively impact a facility’s medical revenue cycle. aJust Solutions has a team of professional Patient’s advocates that can provide help in solving medical bills issues and to reduce medical facilities burden. It is their task to help streamline a positive patient medical experience through providing help with their medical bills and denied claims. Below are six of the common reasons medical claim denial issues may arise at your medical facility.

1. Medical claims are not filed on time

Every medical claim is given a specific amount of time to be submitted and considered for payment. Neglecting to submit a medical claim before its due date often results in a medical practice paying for it at their own expense. Most of the time, medical providers may miss filing medical claims on time due to incomplete or lost superbills, also known as charge tickets or an itemized list of patient services. Even when medical claims are corrected, they can be denied when submitted after their filing date has passed.

2. Inaccurate Insurance ID number on the medical claim

It is the provider’s responsibility to verify a patient’s current ID upon each visit, which includes current changes to medical insurance. Old insurance cards and ID numbers submitted on an original medical claim may not be recognized by an insurance company or payer. Entering information manually can also result in medical coding and billing mistakes, especially if staff members aren’t trained with the proper data entry techniques.

3. Non-covered services

According to payer policy, a service may not be considered medically necessary due to the diagnosis submitted on the medical claim. Even though a patient was given a treatment based on the medical provider’s documentation, the actual diagnosis may not have been communicated to the staff members in charge of the facility’s medical coding and billing management system. While instilling more information about a provider’s services and linked diagnoses, it can still be a challenge preventing coding and billing faults with regards to imprecise documentation.

4. Services are reported separately

There are some procedures that should not be coded or billed together because they are either performed by a single physician or a team. It is also significant to note that physicians may belong to a practice that’s not covered by a patient’s insurance, which is why certain health services should not be piled together. A professional medical coding and billing provider will help reduce medical claim denials and the need for coding edits by familiarizing themselves with the services provided for the patient and the bundling policy of the medical facility.

5. Improper modifier use

Common modifiers, such as modifiers 25 and 59, are used to indicate whether a service or process took place within the same day or on separate days. For instance, modifier 25 stands for an appraisal and organization (E/M) service that was provided on the same day as another service while modifier 59 represents the procedures that took place on different days. Modifier 59 also includes whether the service catered to a different organ, another provider, and doesn’t blend into the typical routine of the original service. In cases where modifiers are used inaccurately, denials are likely to happen. With the assistance of skilled medical coding and billing experts, medical denials can be reduced tremendously by applying the essential common modifiers to the proper service or procedure.

6. Inconsistent data

When data is incorrectly entered on a medical claim, it often results in a denial of the services and procedures provided. A couple of reasons why data discrepancies may happen include an error of gender-specific conditions being documented wrong or imprecise entry of data. It is suggested that practices make use of alert systems whenever an error or inconsistency happens. If an alert system is implemented, the error will keep the denial medical claim from being processed and not denied, which will save providers more time and money.

Taking on Debt from Credit card to Pay Medical Bills

Even if you use all the options possible, medical negotiation does not always work. If you can’t get your medical bill reduced or eliminated by negotiating, there are other choices, such as taking on debt by using a credit card or taking out an unsecured personal advance.

Using a credit card to pay medical bills is not usually recommended because of credit cards’ naturally high interest rates. However, if you’ve tried all negotiating strategies and are still having trouble paying your unpaid balance after the six months’ grace period given by credit reporting medical agencies, it might be better to pay the bill with a credit card than to have your account sent to collections and have a negative effect on your credit report.

Another option that might be work is taking out an unsecured personal loan to pay the medical bills. Personal loans’ interest rates can be significantly lower than those of credit cards, particularly if you have a healthy credit history. They can be used for many purposes and since a fixed-rate, unsecured personal loan is in installment debt—in contrast to the revolving debt of credit cards—the balance is paid on a fixed payment schedule.

 If you qualify for an unsecured personal loan with a manageable interest rate and monthly payment, you can use it to pay off your medical bills immediately and avoid accruing late fees or having the bill move into collections.

More Info: https://ajustsolutions.com/bill-negotiations/

5 Facts About Your Denied Insurance Claim

It’s a fact that not everybody has problems working with their insurance company. It’s a fact that not everybody gets denied their health insurance claim. It’s a fact that not everybody needs an insurance claim lawyer. However, if your insurance company delay your claim, denies your claim, or has acted in bad faith, then the fact is that you will want an insurance litigation attorney or patient advocate on your side.

5 FACTS about health insurance claim practices

1.      Insurance companies are always looking to make money. Although you have been making timely payments, do not trust that the insurance company is in your corner. You usually will have to fight to get the compensation you deserve.

2.      Insurance companies save cash by denying claims. If there is anything doubtful or if they are in doubt, they will reject your health insurance claim.

3.      You do not have to accept he denied insurance claim as the final ruling. You can argue with their decision by filing an appeal with the State Insurance Official.

4.      Your insurance company is obligatory to act in good faith. If the insurer rejects your claim in bad faith, they could be in deep problem.

5.      You can file suit against the healthcare insurance company for a whole contract or bad faith practices.