Medical reimbursement claims are the lifeblood of medical practice. At a busy practice, where the staff is perpetually short of time and multitasking, claim errors may occur frequently. Rejected and denied claims lead to delayed and often, lost revenue.
Medical reimbursements are a complex process. They require diligence and expertise in the initial submission, attention to detect underpayment, and care to follow up or appeal rejected and denied claims.
Omitted, invalid, incorrect patient identity data: Incorrect patient data leads to rejection of the claim. It is crucial to ensure that the name is correctly spelt, the date of birth and gender are correct, and the insurance policy numbers are entered carefully. If a patient has multiple policies, the primary one should be identified.
Medical coding errors: Coding requires specialized, up to date knowledge. Using outdated coding sources, a mismatch in the code and the patient record, and unclear details in the claim, can lead to claim rejection. Specificity is vital, – for example, the code for diabetes is not the same as the one for diabetes type 1.
Under-coding, the filling of a lower-cost procedure in the claim instead of the appropriate one, results in lesser payment than deserved.
Incorrectly filled insurance payor forms: The forms must be filled in completely. Missing data like date of onset or emergency, date of an accident, etc. immediately lead to rejections. It is crucial to scrutinize each claim minutely for missing or incomplete data.
Delayed submissions: This will almost always result in denial. Commercial, Medicare, and the Affordable Care Act (ACA) have different rules, which also change from time to time. The claim must not only be sent within the valid window but must be received within it. The ‘From’ and ‘To’ date fields must be accurately filled.
Improper documentation: Sometimes, a payor will request the patient’s medical records when deciding on a claim. The necessity of procedures, treatment, length of hospital stay, and other matters are judged from the records sent to them. If the record is incomplete, illegible, or does not provide adequate information, the claim may be rejected.
Failure to verify eligibility: This should be done before starting treatment. If the insurance policy has lapsed or does not cover the treatment being provided, the claim will be denied. Similarly, if preauthorization was required but not obtained, the claim will be denied.
Medical claims errors have a significant negative effect on the amount and timeliness of reimbursements. Very often, the Explanations of Benefits (EOB) form (that accompanies claim reduction or rejection) is either not attended to or is found too difficult and given up. This results in revenue being lost.
Some errors can be grave:
These are usually human errors, but frequent occurrence can lead to practice or clinic being blacklisted. In worse case scenarios, proceedings under 18 U.S.C. § 1035 and 18 U.S.C. § 1347 (dealing with health care fraud) could be initiated. The Federal Civil False Claims Act includes both civil and criminal penalties and makes no provision for lack of intent.
Claims are the primary source of income for a practice. Many practices do it in-house to have control and reduce expenses. Most small practices delegate the task of claim submission to the receptionist, who has several other responsibilities. Hurried and erroneous claims can lead to a significant proportion of claims being denied or rejected.
This avoidable loss can be eliminated by hiring a dedicated staff member for coding and claims submission. This will, of course, add substantially to the clinic’s expenses. A well-chosen practice management software complements and aids human efforts. It automates the claims process, picks the right codes, and prepares the claims, thereby reducing errors substantially and increasing the collection rates. Moreover, analytical reports enable decision-making by prioritizing claims to be followed up and more.
Another option is to partner with billing and claims experts. Such organizations enable the submission of error-free claims and an effective follow-up on denied and rejected claims. They also help with complicated Claims like Workmen’s Compensation and No-Fault Billing.
Outsourcing medical claim management, or using robust practice management software may involve some upfront efforts and costs, but the long-term benefits far outweigh the costs. While your claim errors reduce substantially with these solutions, your cash flow as well as overall efficiency improves.
Do not let repetitive claim errors impact your bottom line!
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