Don't fall victim to Insurance Companies - Karen Wilson - RMS Content Writer

Running a medical practice can be very challenging in itself, billing and coding do not make it any easier. Most medical practices always battle denied claims from time to time which affect their efficiency and productivity. Usually, it is possible for denied claims to be appealed and sent back to the payer for processing. However, the process is time-consuming and may still end up denied; especially when the claims violate the payer-patient contract or are not included in the patient's coverage.

Denied claims are quite different from rejected claims. In the case of a denied claim, the claims have been processed by the payer and tagged unpayable. The payer may include an Explanation of Benefits (EOB) for the claim denial but getting as many proper claims as possible at first reduces cost and chances of denial.

Here are some common causes of claim denials faced in the industry:

·        Non-specific coding- This ranges from wrong codes to too few or too many codes or even missing codes for the procedure or service performed by another physician. Codes are also being updated over time, so it is common to see claim denials due to coding issues.

·       Including benefits for a procedure or service within another different procedure. This often happens with similar or related procedures carried out on a patient.

·       Patient does not meet eligibility or coverage requirements. People change insurance provider and employers also tend to go for reduced coverage plans. Some are partial coverage and cannot go for the same claim as full coverage. Improper categorization while billing and wrong codes will automatically mean denial.

·       There is a stipulated time limit for filing claims which will vary from payer to payer. Exceeding the time limit will result in the claim being denied.

·       Missing patient's information like social security number, wrong modifiers, also contributes to claim denial.

·       Duplication of the service undergone will not be honored by the payer too.

It is sometimes better to cosource/outsource medical billing and coding. Most practices can not afford not to cosource or outsource to protect their practice. At RMS, we eliminate the herculean procedure of preparing claims that are payable. By helping you stay up to date with current billing and coding trends for optimal claim reimbursement, analyze payer denials records and fix them. In addition, we work with payers from time to time to review contract requirements and integrate software solutions to handle the claim process right from billing to coding. We improve timely revenue collection with our advanced technological tools that can track mistakes, prevent duplicate claims submissions, manage claim submission, proper documentation for timely claims and other billing requirements.