A clinical medical billing claim that gets denied after filing is not an easy process to manage. The technical requirements can be very frustrating and expensive as well as time consuming. In the end, it’s always better to avoid denied claims from the start rather than going through the hassle of filing, getting denied, and having to resubmit. While there are many factors that could lead to a claim being denied, below are some common reasons why denials occur and what you can do about them in order to reduce the chances of your claim being denied from the start.

Stay updated with the latest coding rules:

Medical coding undergoes continuous revisions in norms and standards. Coders must be well-versed in both traditional and new coding conventions. They have to do so to ensure that all claims are accurate. 

Some diagnosis and treatment codes are revised once a year. So, you should timely modify or remove it. Investing in staff training on coding changes will assist in preventing coding errors. Your claim will be rejected if your invoice has an incorrect code. The simplest approach to prevent making this mistake is to have the most recent software editions of your codes on hand.

Evaluate the Coding Practices:

If a percentage of the claim denials are due to a lack of medical necessity, you must provide further information to the payor. The easiest method to avoid this in the first instance is to ensure that physicians, coding, and billing personnel communicate effectively and receive the proper authorizations in advance. Look for similarities in the medical necessity rejections and set up appropriate protocols to avoid these denials while keeping track of them.

medical billing claims

Optimize Data Quality:

Before treating the patients, front office employees have to do some work. They should verify their eligibility and determine if the insurance can reimburse their treatment. Simple clerical errors, including incorrect recording of patients’ names or treatments, incorrect DOB, etc., can lead to rejection of medical billing claims. The client won’t necessarily reject the reimbursement but can give the claim back to your staff, wasting considerable time and resources. 

An instance of a claim getting refused due to data quality might be a medical code entered incorrectly. At the same time, you might address this by avoiding it in the first position, which begins with enhancing the data quality of each claim. It’s best to double-check any numerical information of the patient. 

Prioritize Pre-authorization:

Failure to obtain pre-authorization might be detrimental to your clinic. Your business management software can help by highlighting standard guidelines and insurers so that your team knows what to do. However, your staff must be aware of which carriers demand pre-authorization and for what. 

Furthermore, it is preferable to obtain pre-authorization for a surgery that will not be performed instead of performing a treatment and then attempting to obtain retroactive authorization. Some practices have succeeded by allocating particular personnel to this procedure. So, keep that in mind if your workloads are high.

medical billing claims

File the Claims Timely:

Time is valuable. Each insurance policy has a time limit for filing a claim. Has any of the claims taken a lot of your time? Are providers not completing their charts within a few day of the service? Some insurance policies deny for timely filing in as little as 90 days from the date of service, while others are more liberal and grant up to one year.

Automate the Denial Management:

Getting business insight to measure and classify denials requires technology and analytics. You must follow up, evaluate, and inform on advancements by a physician, division, process, and insurer. This information will assist you in identifying and monitoring denial patterns, determining the resources required to execute solutions, and monitoring and reporting progress.

Denial management is important as it will save your time and effort if done properly. Not sure how you can carry it out? Discuss with NEMB and hire the top medical filing specialists today! The team has a flexible business model that can surely help your processes.


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