Insurance reimbursements are the bread and butter of most medical practices, so it's critical to keep track of claims and investigate the reasons for denials. Without that follow up, experts said, you're bound to repeat the same errors that caused the denials and miss chances to boost revenue through legitimate appeals.
"Denial management is part of the revenue cycle," said Jeffrey Milburn, a healthcare consultant with the Medical Group Management Association. "In some cases, practices are blowing off substantial dollars because processing denials is more work than someone wants to go through.”
Even the smallest practices should have a claims review process in place, experts said. It's important not only to trigger appeals but also to alert you to internal problems or trends that may be causing some denials.
"When you spot those trends, look on them as learning opportunities," said P.J. Cloud-Moulds, head of consulting firm Turnaround Medical AR Recovery. "Each one is an opportunity for you to stop that problem from happening again."
Consider the following tips from coding and practice management experts for keeping on top of claims issues so that you can spot problems early and take steps to maximize your reimbursements.
Prioritize denials. Don't lump claims processing and denial management together, said Milburn. Instead, designate someone in your office "with the mind of a collector" to specialize in denials. "Sometimes the person going through the explanations of benefits is just trying to get through their batch as quickly as possible and they don't want to interrupt their work flow to track a denial," he said. "They should be able to transfer those cases to someone else whose job it is to research the denial and chase down the appeal."
Monitor accounts receivable (A/R). "It's really important that practices look at their A/R on a monthly basis," said Melody Irvine, owner of Career Coders, a medical billing and coding school. Investigate any claims that haven't been paid after 60 days to make sure they have been filed correctly and are being processed. Most insurers have a 90-day filing window, after which time physicians can no longer bill for a service, she said.
Look for red flags. Persistent patterns in claim underpayments or denials should be investigated further, said Milburn. For example, if one type of claim is consistently being downcoded to a lower payment level, it may signal an internal coding or documentation problem that can be addressed and fixed. With some claims, you may be hurting yourself by submitting too much information, said Cloud-Moulds. If an insurer has a policy of approving a maximum of four CPT codes for a single diagnosis and you submit five, chances are they may drop the one associated with the highest reimbursement and pay the lesser amounts. "You can get paid more if you leave out the least-expensive code," she said. "As long as it's documented in the medical record, it does not necessarily have to be billed."
Pursue appeals. No reasonable appeal is too small to consider, experts said, especially since most EHRs make it easy to electronically resubmit claims. Plus, "over 50 percent of claims that are appealed get paid," noted Irvine. After filing an appeal, follow up with the payer to make sure it is being processed. If you can't get resolution, consider getting the patient involved, said Cloud-Moulds. "Patients often don't understand that the physician can pass on an unpaid balance to the patient," she said. "Patients may be willing to call their plan to see what they can do to get it paid." If your appeal is denied, you or the patient can also request an external review through your state insurance department.
The American Medical Association's website has more information about identifying payment issues and appealing claims, including sample appeal letters that can be downloaded by members.