Recoup lost revenue by following up on denials.
After a claim has been properly documented, coded, and submitted for payment, a few things could happen. Hopefully, the insurer pays the claim and the office receives the appropriate reimbursement. But there are other scenarios that could also happen that require follow-up. Let’s review some of them next:
Pick low hanging fruit first. The insurer may reject the claim because of an error on the claim itself. This could be a simple mistake like a required field being left blank, a code being truncated, or the claim not having the appropriate designation of who provided the service. A rejected claim doesn’t even make it in the door at the insurance company. The good thing about these types of claims, though, is that after the correction is made, the claim can be resubmitted.
Know the rules. The insurer may deny a claim for a multitude of reasons. Perhaps the service was not medically relevant for the patient, too many services were provided in a given period of time, or no authorization had been made prior to the service being rendered. These are just a few of the many reasons an insurer may deny a claim.
It’s up to the coder to know what codes can be submitted with what diagnoses and what additional documentation might be necessary for the service to be appropriately submitted and paid. Different insurances reimburse differently. Not all insurances, or payers, cover the same services and procedures. Coders need to be familiar with payers’ coding, billing, and reimbursement rules to ensure they code correctly. This is why it cannot be stressed enough that all reference material should always be current and all bookmarked website sources should be updated regularly to make certain the most current information is being used.
Take a team approach. Even when all the requirements are met and the claim is completed appropriately, there still may be a reason it is denied. Your follow-up team could include insurance specialists, clinicians, customer service representatives, and coders.
Creating a full-service follow-up team affords the practice or group the ability to follow through on all claims to the various paying entities as well as answer patient questions about their bills and claims. The follow-up team should have the knowledge to know what to do for each claim that is not reimbursed in a timely fashion.
The following examples outline reasons why payers may deny bills, or claims, that the providers send:
This follow-up team, made up of billing and/or collections specialists, is only as good as the information they receive. That is why the entire revenue cycle must be thorough and timely. If the scheduler doesn’t gather the most current insurance information, no matter how detailed the documentation and skilled the coder, the claim may be denied. If the physician doesn’t document a service fully or at all, the revenue cycle stumbles. All of the gears of the revenue cycle should be well-oiled and comprehensively maintained, meaning that the entire team working for a provider must perform their duties correctly and on time.
Get to know Coding Principles
Medical Coding Demystified: Coding 101 for Non-coders 2018 is an indispensable resource to learn medical coding.