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5 proven denial prevention strategies for your medical practice

October 14, 2021
5 proven denial management strategies

Medical coding and billing involve complex processes that differ depending on the patient, insurer, and procedure. Even the most diligent practices experience claim denials, but knowing the most common mistakes can help you take steps to avoid them and help you build a strategy for denial prevention.

Let’s take a closer look at five common billing mistakes and how they can aid your denial prevention strategy.

#1: Code to the highest level of specificity

Coding to the highest level of specificity is the best way to avoid denials.

Coding specificity is a shared responsibility between the provider, coder, and biller to create a clear clinical picture of the patient encounter.

Healthcare providers should document conditions to the full extent of their clinical knowledge of the patient’s health.

It is equally important that coders assign diagnosis codes to the highest degree of specificity documented. Codes ending in the numbers zero or nine often indicate an unspecified diagnosis. If your coders see these numbers, it is a good indication that a second review is required to determine more specificity.

Your last fail-safe is with your biller. Facilitate dialogue between your billers and coders. Most billers only have a basic knowledge of coding, so make sure your billers know what unspecified codes look like so they can catch them before claim submission.

By having all parties educated and focused on coding to the maximum level of specificity, you can avoid denials.

#2: Avoid missing information for denial prevention

Any missing information on the medical claim may cause a denied claim. Some of the most common missing items include date of accident, date of medical emergency, and date of onset. Be sure to scrutinize all claims for missed fields and required supporting documentation.

Simple inaccuracies in patient information can also lead to denials. When entering your patient demographics, it’s essential to ensure the accuracy of the patient’s name, date of birth, sex, insurance payer, and policy number. It’s also good to check whether the claim requires a group number and if the patient’s relationship to the insured is accurate.

#3: Ensure timely filing

Timely filing denials are the most frustrating denial a practice can encounter. But since every payer operates on their own filing deadline schedule, it can be easy to miss the window if you’re not careful.

Some deadlines can be as short as 30 days, while some can be as long as two years. It is essential to follow these guidelines, or insurance companies may deny the claim for timely filing.

One recommendation is to have your billers keep a list of general payer deadlines handy. That way, they can always reference what the timely filing limit is. It is also a good practice to track and document each payer’s receipt of claim submissions when possible.

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#4: Eliminate duplicate billing for better denial prevention

Healthcare Finance states that the largest percentage of denied claims comes from duplicates. More specifically, they result from practices resubmitting claims before receiving the initial response from their insurance payers. To minimize these occurrences, create a process that will help you keep a firm handle on your claims inventory.

Many practice management systems allow users to note activity on claims. Instruct your users to leverage these features so that everybody in the practice can see what actions others have taken.

It is also essential to work on your claims regularly and keep your rejection queues as organized as possible.

#5: Check that the service is covered

Not verifying insurance coverage is one of the top five reasons for denials. Because insurance information can change at any time, even for regular patients, the practice must verify the patient’s eligibility each time a visit occurs.

A best practice is to confirm eligibility at the time of booking, before the appointment, and when the patient arrives during check-in.

There are four common denials associated with insurance verification:

  • Members coverage terminated or not eligible for this date of service
  • Services not authorized
  • Services not covered by plan benefits
  • Maximum benefits met

When your checking eligibility, here are the items you should be verifying:

  • Patient’s policy status and effective date of coverage on the date of service
  • Type of plan and coverage details
  • Payable benefits
  • Out of pocket expenses (co-pays, co-insurance, deductibles)
  • Plan exclusions
  • Claims mailing address and electronic payer id
  • Referral and pre-authorization requirements

By incorporating simple denial prevention strategies into your everyday workflow, you can avoid denials and keep your practice revenue flowing.

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