Payers may deny payment for any number of reasons—some reasonable, others arguably a bit arcane. Because of this, look to revamping your workflow in 2018 to include a process that will not only identify denials but will provide a firm footing to get them reversed. Integrating denial prevention into this strategy can do more than assure payments now; it will equate to long-term success for the independent practice. (See my free white paper on this and other key revenue topics, Getting Paid in 2018: What Independent Medical Practices Need to Know.)
Payment challenges emanate from pre-adjudication clearinghouse rejections, as well as payers’ claims processing denials. Here are some quick strategies for independent practices to address the most common sources of non-payments:
The most common denial relates to insurance eligibility; it’s not uncommon for the insurance to have lapsed or the patient to have switched policies without informing the practice. In order to avoid these denials, it’s vital to confirm insurance coverage and benefits eligibility prior to patients being seen. Integrate this financial clearance process into the scheduling workflow for optimal results.
Anticipate Referrals and Authorizations
Make sure physicians and staff understand payers' requirements in this area, and prepare to meet and even exceed them. Most payers allow for authorizations to be granted via an online request process; regardless, save all correspondence in the patient’s account; for telephone communications, keep copious notes, including the reference number for the call, as well as the date, time, name and extension number of the payer representative who was contacted.
Recognize Medical Necessity
Be aware of payers' medical necessity policies, and prepare to discontinue, write off or have patients pay for services that a payer won't cover (unless contract restrictions disallow this tactic). Consider these questions:
- What services are payers denying for medical necessity?
- Are they valid denials?
- If appealed, does the payer reconsider payment?
- Does the payer outline any policies that will reveal a potential denial for medical necessity before they are performed?
- Engage the patient in a three-way call with the payer; patients can be the practice’s number-one advocate for obtaining payment.
Determine the payers' coding policies, and learn what to expect. Consider these questions:
- What services are the payers denying due to incorrect coding?
- Does the payer follow the prevailing national coding guidelines, such as recognition of modifiers and the Correct Coding Initiative?
- Does the payer outline any policies that can reveal in advance that a service will be denied because the payer considers it bundled with something else?
- Understanding payment policies — from multiple procedure reductions to payment for unlisted procedure codes — for the services commonly rendered by providers in the practice is vital for success.
The majority of denials are caused by errors made at the front desk. The single task that a receptionist can perform to reduce denials is to capture the correct insurance and demographic information from patients. If they don't get this right, the claim can go to the wrong party. Plus, denials based on incorrect insurance or demographic information are high-probability candidates for write-offs because the effort to re-work them often drags on past the payer’s timely filing deadline.
Rejections and denials are most commonly caused by staff error. Auto eligibility checks and other practice management software features can help flag and/or correct errors.
A staff member should held accountable for determining the nature of each denial, contacting the insurance company to discuss it, gathering more information (e.g., an office note to substantiate a -25 modifier) and resubmitting the claim with any new data obtained.
There’s not one ideal route to implementing denial prevention and remediation. One can take the do-it-yourself (DIY) route or seek the assistance of software that provides standard appeal letters to use. Some practices have developed sophisticated denial management systems that are automated to send claims appeals based on the payer’s reason for denial code. Whether one is a DIY-er or relies on intricate tools, never automatically write anything off! If the providers did the work, they deserve to get paid; it’s up to the practice team to doggedly pursue payment while repairing the internal causes.