In today’s frantic and fast paced world where revenue generation is more important than ever in dictating the longevity of any business, health care is no different. Even the mere hint of a claim being denied or rejected is enough to haunt any practice and can have serious impediments on the financial growth of the practice. A denied claim is not only an indication of an extra work but also means delayed revenue generation. A single claim may not have a power of crippling revenue cycle but let them pile up for whatever reason and they can wreck a havoc for any practice, sabotaging their financial output. No practice is able to sustain let alone thrive in the face of financial resources being restrained. So, it is crucial to let the wheel of the successful claims be churned.
The financial success and stability of any practice is equally divided between the mastery of his/her respective specialty and the vigilance and carefulness he/she put in preparing of the claims. No matter how much a practice familiarizes himself with the nuances and gradations of his field, the financial success relies heavily on the successful claim submissions which yield the maximum and timely revenue generation helping the practice moving forward. In a nutshell, the more the processes are to be streamlined the more will be the reimbursements.
Even so practices and health care facilities have come a long way, denied claims are still a reality and happen more than often inflicting a great deal of pain for the practices. Before we deep dived any further into the tips and tricks of recovering of the denied claims, it is equally important to have the understanding of how to prepare successful claims.

Verify the Insurance and Eligibility

Failing to verify insurance and eligibility of the patient visiting health care professional results in billing discrepancies which leads to financial losses for the practice. The staff employed by the health care professional should be well-versed with the process of verifying not only patient’s demographics but also able to ensure the insurance information and eligibility. Even if a patient has been seeing a certain health care professional for some time, it is wise to check patient’s coverage at his/her every visit.

Claims with Missing Information

Insurance companies are wired to deny any claim which has missing or an incomplete information. Even leaving one field blank or wrongly entered can land a denied strike. The most common mistakes while entering and verifying patient’s information are:
Patient Name
Date of Birth (DOB)
Gender
Insurance Payer
Policy Number
Group Number (if required)
Primary Insurance (in case of multiple insurances)
So, practices need to be mindful when entering information for claim submission in order to avoid claims being denied and maximum the reimbursements.

Claims Not Filed on Time

Clean and timely claim submissions is the bread and butter of any medical billing process. Different payers have different deadlines for claims submission. They range from 90 days to even a whole year or can be as short as 15 to 30 days. Dilly-dallying with claims submission for any reason will disrupt the revenue cycle. Make an effort to track and document each payer’s receipt of claim submission so that the claim submission window will not be missed.

Accurate and Efficient Medical Coding

Medical coding is crucial for the submission of clean and accurate claims. Medical coders convert diagnosis, medical procedures, services, treatments and equipment used by doctors and physicians into alphanumeric codes. If the services and procedures given by a health care professional not decoded correctly they will result in the denial of the claims. Therefore, it is vital to have clear communication between medical coders and billers to avoid denial of the clams.


Payer Rules and Regulations

The rules and regulations of claim submission are continuously changing and updating. So, in order to avoid claims being denied or rejected it is important for the practice and his billing staff to keep themselves up to date with the changes taking place in the rules and regulations of the payers.


Legible Documentation
The reason of a clear documentation of the services provided is to ensure safe, thorough, accurate and efficient care of the patient. Not only that but it also helps the practice to get paid by the patient’s insurer. If the insurers are unable to find or understand the services given by the practices, they will simply deny the claims. So, the practices should be extra careful in documenting all the essentials required to get paid by the insurers effectively and efficiently.
Now, let’s discuss the steps needed to be taken after the claim is denied.


Review Denied Claim Notifications Whenever a practice receives a notification from the insurance company regarding the claim whether it is remittance advice, explanation of benefits (EOBs) or any other, the practice needs to review it carefully. The notification should be able to indicate and state the reasons of the denial of the claim. In such case follow the instructions of the payers in order to resubmit the denied claim. Generally, there is a missing or incorrect patient information which is needed to be filled or corrected and resubmitted as soon as possible. Other times it is CPT codes error, which contains the wrong entrance of procedures and diagnosis. Correct the errors and resubmit the claim.
In case if the notification from payer is not clear enough, call them for more information. It can very well happen that upon calling and discussing, practice comes to know that the claim was arbitrated on false grounds. Or the practice may come to know that the submission procedure is not in conjunction with the requirements laid by the insurer.

Persistence in Appealing

Another scenario is that the practice resubmits the claim but it is denied again by the payer. Practice however believes that the denial is not on factual grounds. In such case practice has the option to go in to the appeal against the improper denial of the claim according to the carrier’s guidelines. Keep in mind however that the appeal procedures are liable to vary by both insurance companies and the state law.

The appeal should have an explanation of practice’s case reconsideration request along with the necessary documentation, for instance copy of the claim denied and any copies of earlier communication with the company about that particular case. It may take more than one try to successfully resubmit the claim. So, don’t give up, persistence is the key.

Avoid Delaying

It is crucial to submit and resubmit claims in a time window specified by the payers. Failing to comply results in the requests for recommendation of the claim to be denied. So the practice should keep itself updated with different timelines for different payers to avoid any hassle.

Understanding Appeal Process/b>

Before the submission of an appeal health care professionals should familiarize themselves with insurance companies appeal processes. This will help the practices to be in better positions to respond to the payers actions. Carriers have this information on their websites. If not ask them for the required information. In a nutshell, be updated it will help in the resubmission of the claims.

Maintain Records

It is crucial to keep and maintain records over disputed claims. Practices should keep the record of the information they get from the payers offices along with the names of the representatives they speak with. Such information helps the practices to contest their cases and its outcomes. These records also help the practices to take further actions on the claims and also aid them to take preemptive measures for further submissions.

Error Free Documents

The claim appeal letter has to be perfect. It is no brainer. However, it is also important that documentation and reporting backing the appeal letter should be completely free of mistakes. Most of the times the errors related to denial claims are of CPT codes and sometimes patient’s missing information. CPT codes errors normally include inconsistent or mismatched coding that is procedures, diagnosis, outdated codes or insufficient specialty. Therefore, ensure all codes match up with existing medical documentation before the resubmission of the claim.