Submitting clean medical claims reduces denials, accelerates processing, and ensures maximum return. Clean claims contain complete, accurate demographics and insurance details, and are compliant with current federal and state regulations. Despite the criticality of clean claims, deficient and inaccurate data continues to plague billers.
According to ZOLL Data Systems’ internal analysis, more than 65 percent of records run through their AR optimization solution are missing some data, most often name, address, Social Security number, or a combination of fields. A claim missing the patient’s middle initial probably would not be denied, but one that is missing the generational suffix “Jr.” could be. The trickle-down impact prolongs billing processing time, increases denials, and impedes cash flow for medical providers and the billing companies that serve them. In the worst cases, claims extend beyond the permissible window for claim submission or resubmission, resulting in lost revenue opportunities.
All medical billing companies must weigh the need for clean claims against the staffing and financial resources needed to ensure them. There are practical steps that you can take to improve your chances of capturing complete, accurate patient data necessary for clean claims while also creating a more efficient, cost-effective workflow.
This article takes a look at several new strategies billing companies can apply to partner with their clients and to increase clean claim rates in the year ahead.
Top Reasons for Medical Claim Denials
A claim typically goes out electronically to the payer, where it will be rejected or accepted. Many companies use a clearinghouse on the front end to check eligibility and either approve a clean claim or send a rejected claim back for error correction. The claim is “scrubbed” for accuracy: policy number, diagnosis codes, demographic information, and other specific criteria. If the claim makes it through the approval/correction process, ideally the payer will accept, process, and pay the claim. Unfortunately, this scenario does not reflect reality across the board, and denials continue to pose a significant challenge for many billers.
Denials occur for a number of reasons. Some are related to eligibility criteria, provider enrollment, or the patient’s plan. According to a December 2020 poll conducted by the Medical Group Management Association (MGMA), 42 percent of healthcare leaders reported prior authorization as the top reason for denials in their organization, followed by demographic issues (29 percent), and timely filing (7 percent). Another 22 percent reported “other” reasons, including CPT® codes (23 percent), payer requirement inconsistencies (14 percent), medical necessity requirements (14 percent), missing information/documentation (11 percent), and coordination of benefits (9 percent).
In our experience, payers are notorious for rejecting emergency medicine claims. Especially with COVID-19, hospitals have seen many more acute patients who required emergency medical treatment. If a payer denies treatment that is deemed to be a medical necessity, we may be able to fight the judgment. One of the biggest challenges we face is getting payers to understand that people experience legitimate emergencies that require ER visits.
In nonemergent scenarios, if a patient’s plan doesn’t meet the criteria for the diagnosis, the claim is denied and the explanation of benefits (EOB) goes through the clearinghouse, and then to the billing system. Depending on the type of denial, an accounts receivables (AR) work team determines whether an appeal is appropriate. If not, the patient is responsible for the bill, which falls into the self-pay category.
Denial Trend Predicted to Continue in 2021
Looking ahead to 2021, denial trends for billing companies are expected to continue, especially those related to the pandemic. One denial type we expect to see increase is “no support,” when the payer deems the medical record doesn’t support the level of service submitted.
Consider the example of COVID-19 patients: extreme vigilance is needed to accurately document and report the type and severity of the wide-ranging symptoms associated with coronavirus. To simply state “suspected COVID-19” without details justifying the specific treatments is not sufficient for a clean claim. We’re seeing higher acuity in patients who delayed needed care due to COVID-19 safety concerns and increased volumes in the ER. Even with the vaccine becoming widely available, we anticipate seeing higher acuity cases presenting in the ER for some time to come.
Cleaner Claims Begin with Collaborative Denial Prevention
As with healthcare, prevention is the key. For medical billing companies, denial prevention is critical for increasing the clean claim rate for capturing maximum revenue. How can billing companies work proactively with their customers to prevent denials? A best practice is to establish a collaborative partnership that helps to ensure billing data integrity in four ways:
- Billing systems are continually updated with new insurance information such as address changes and other demographic updates.
- Real-time technologies such as insurance discovery, demographic verification, and insurance verification are deployed and used collaboratively across organizations.
- IT teams work together to check the efficacy of system interfaces and confirm that systems are up to date.
- Documentation education teams routinely meet with clients’ providers to review their medical records to improve the chances of meeting medical necessity reviews or justifying levels of care for noncovered emergency services.
At Keystone HealthcareTM, our documentation education team has established a proactive process with our providers to identify documentation issues and trends that prevent proper reimbursement. The team includes both clinical and billing members who connect documentation, coding, and billing teams to help providers understand what is required for accurate payment. When a denial occurs, the documentation education team is also engaged to help with the appeal process.
Strategies for Preventing and Mitigating Denials in 2021
Denials are frustrating, but there are actions billing companies can take to increase their clean claim rate and to mitigate denials:
- Get the facts. Validate the patient’s contact information and verify demographics.
- Get prior authorization. Determine reimbursement requirements for documentation, history, and other information up front.
- Scrutinize self-pay. Search up front for hidden coverage for all self-pay patients—the earlier in the process, the better.
- Analyze risk/reward. Evaluate self-pay cases, define propensity to pay, and determine who qualifies for financial assistance—patients need individual billing plans if you want to optimize revenue.
- Verify insurance. Find the right payer the first time and minimize duplicate work.
- Track and report denials. Quantify every month by date of service per client and share that report with your management team.
- Catch new denials early in the process. CMS and other payers continually add denial reasons. Know where denials are coming from and identify the best response to specific denials and for specific payers. Some payers want all documentation, while others want only provider notes.
- Designate an AR team. Task it with staying on top of what payers want when it comes to reconsiderations and appeals.
- Be flexible when you encounter a new denial reason. Contact the payer for clarification to understand what they need and aim to resubmit a clean claim.
- Dig into payers’ newsletters and watch for updates on their websites.
- Hold regular, timely meetings. Share all available communication with your team. Understand how new information impacts your practice and your clients.
- Evaluate new technologies. Determine the best technology fit for your organization’s overall strategy to submit clean claims, reduce denials, and sustain optimal billing practices in 2021 and beyond.
Follow These Strategies to Prevent and Mitigate Denials
When billing companies follow these strategies for preventing and mitigating denials, frustration decreases, and the number of clean claim rates increases. If you need in-house patient billing services, we can help. We offer medical patient billing services that prevent you, or us, from outsourcing this function. Contact us today.