Getting insurance claims right the first time is the best way to ensure smooth sailing through the clearinghouse water and getting paid fast. A rejected claim with errors slows down the payment process, which has an unwanted impact on your practice’s cash flow. The best way to avoid rejections is to submit “clean” claims.
In this article, we will discuss what makes a clean claim, the basics of claim rejections, and providing you with 9 tips on how to best submit a clean claim to minimize those rejections.
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What Is a Rejected Claim?
A rejected claim has one or more errors that do not meet the specific data requirements of your clearinghouse. The clearinghouse has a claim “scrubbing” process that compares the data in your claim to rules about how that data should be presented and in most cases checks the patient’s insurance eligibility. If your claim has errors and doesn’t match the data requirements, then your claim is rejected by the clearinghouse and sent back to your practice to be corrected. In this case it never even gets close to the insurance company.
Claims that go right through the clearinghouse without errors are considered “clean” claims. As you can imagine, the goal is to submit clean claims 100% of the time.
What Causes a Claim to be Rejected?
Let’s start by running down a list of several well-known reasons claims get rejected.
Incorrect Patient Demographics - This can include using a nickname instead of the name on file with insurance company, an incorrect date of birth, the wrong insurance ID, missing information, or submitting to the wrong insurance.
Incorrect Coding – Using the wrong CPT code, an ICD-10 code that does not match the CPT code, or the wrong modifier are all cause for a rejection.
Incorrect Place of Service – Was the service performed in the office, at the hospital, inpatient or outpatient, emergency room or nursing home? Each place has a different two-digit code that must match the CPT code.
Out of Date Information – Using patient information that is out of date or an old CPT or diagnosis code.
Duplicate Claim – Submitting the same claim again whether by accident or on purpose.
Eligibility - Patient is not eligible or has no insurance coverage.
9 Tips to Help Reduce Claim Rejections
A strong attention to detail is crucial in obtaining a clean claim and avoiding rejections. Here are a few practical tips you can use to minimize your claim rejections.
1. Double Check Your Work
Typos are very easy to make, especially when you are working fast to get the job done. Forgetting a digit in an insurance ID number or simply transposing a number will cause your claim to be rejected. Being diligent about double checking your work will automatically reduce the risk of denial.
2. Talk to the Front Desk
The front desk usually collects the patient and insurance information that gets entered into the computer system. Billing needs to communicate and work closely with them to be able to obtain correct information. Getting updated information from patients at each visit will help to get your claim paid.
3. Verify Patient Coverage
Make sure you have the correct insurance information to bill the claim by verifying eligibility of coverage at each visit. Your billing software should be able to do this for you.
4. Stay Up-to-Date on Insurance Carrier Requirements
Monitor your claim denials on a regular basis. Something as simple as a new insurance company requirement that your biller did not know about can lead to multiple claim rejections.
5. File Claims Within 24 Hours
Avoid timely filing issues and file claims immediately. You may have to put a claim on hold to obtain correct billing information or ask the doctor about a code, but don’t forget about it. A good medical billing software package has a way to take those claims easily. It’s also important that you work the claim rejections right away, as time is of the essence in both cases.
6. Preauthorization and Other Numbers
Make sure that any authorization numbers, CLIA numbers or NDC numbers for medications, vaccines and injectables are submitted with the claim. These are easy to find through many helpful websites, as these numbers are required by the FDA.
7. Submit to Correct Insurance
It should come as no surprise that selecting the wrong insurance company to send your claim to will result in a speedy rejection. This is another reason it’s so important for the front desk staff to verify insurance with the patient at each and every visit. Bonus tip: if the patient has multiple insurance carriers make sure to select the correct one as primary.
8. Insurance Participation
A Provider that is not participating with insurance may also cause your claim to be rejected. If your providers are not credentialed with insurance carriers it’s important to have a system in place to provide your patient an estimate and have them pay in cash.
9. Train Staff
Train your billing staff to handle rejections quickly. As I mentioned above, time is of the essence on both sides of the fence, not just when submitting. Far too many claims never get paid simply because rejections aren’t handled appropriately and that can be a huge drain on your practices earnings.
Bonus Tip: Choosing a Good Billing Software & Clearinghouse
Not all billing software is created equal. Look for these services and features that help automate and reduce errors in the claims process:
Electronic patient intake to reduce manual data entry and errors
Free clearinghouse setup to submit claims electronically
Claim scrubbing to eliminate errors before the clearinghouse
Easy and quick eligibility checks within the software
Billing analytics to manage and improve insurance reimbursements
Built-in EHR for streamlined integration between patient care and billing data
Using an Outside Medical Billing Company
There is a lot of work involved to ensure you are submitting a clean claim. Many practices struggle with rejected and denied claims and have turned to outside billing companies for help. These firms have experienced billers and coders that are qualified to deal with the complexities of medical billing. Outsourcing billing could be a great choice for your practice as it takes the burden of medical billing off of your staff so you can focus on patient care.