First Pass Recovery Rate: How to Eliminate Claim Denials

December 21, 2013

Stopping consistent denials at your practice is not only possible, but necessary. Take these steps to get your first pass recovery rate above 90 percent.

Do you know what your first pass recovery rate (FPRR) is? Find out today and start making a plan of improvement. I've spoken with so many people that think a 60 percent or even 75 percent FPRR is "acceptable." Well, what do I say to that? Whatever you are willing to accept is exactly what you are going to get. Do not fall victim to think type of thinking. I am willing to accept zero denials. Realistic? Probably not, but it drives me to problem solve in every area that I can and continually improve that FPRR.

To have a healthy medical practice these days means you need to take responsibility for all areas of the business. Not just seeing patients, or manning the phones, or sending the claims out. Today is the day to step back and review all of the departments in your practice and locate the areas where you have delegated responsibility. Most likely you are looking directly at your billing department. In-house or outsourced, either way you need to understand that just because "that's their job and what I pay them for" does not mean that those staff members are bought in to your expectation. Most often they do not live up to that expectation, if it was ever explained to them in the first place.

Here are some tips for regaining this control and managing it to your liking:

• Sit down with your billing department and ask them about your FPRR. Most likely they will not know. Ask them to find out. This is a bit scary for someone who does not understand where to find this information. Basically, they need to look at the number of denials versus the number of claims that have gone out. Look for any rebilling of claims.

•Get past the "that's their job, not mine" attitude today. Drop that bag of bricks and realize that this is your business. By giving that amount of control to an entity that does not always have your best interests in mind is where you will find the breakdown.

• Provide requirements and expectations to the staff. I want my FPRR to be consistently above 90 percent. They may laugh or gasp at the request. Stand firm. It's not a suggestion, it's a requirement. Tell them that over the next 30 days you want documentation of every denial that comes through the process. At the end of the 30 days, sit down with them again and provide suggestions as to how you can help them eliminate those denials. Are modifiers needed that are not being provided? Does an insurance company consistently deny a specific code? Is authorization being missed and not provided? Are they missing documentation? Teach them how to identify a weak area and put changes in your process in place to eliminate those issues.

The attitude of "it's good enough" or the argument of "industry standard" should be eliminated from your vocabulary. Your practice will not withstand ordinary or middle-of-the-road any longer. You will be that slow buffalo in the pack and you will close your doors. Do not fall victim to this type of thinking. It's your practice. Own it.