Understanding Your Claims Denials

March 19, 2016

When you look at your cash inflow each month, are you disappointed? That's why it is so important to identify why your claims are being denied.

Do you remember when you were young and sitting at the beach, you would dig a hole? Then slowly it would fill up with water, or the sand would just keep filling the hole in, so you would dig harder and faster? Yet, the sand and water still filled the hole. This is not much different than managing your accounts receivable (A/R).

If you are simply working hard, or hiring more people to manage your A/R, this tells me that you are not stopping the problems from happening, so the A/R hole keeps filling up. There are simple steps you can take to "stop the bleeding" and identify the worst denial offenders that can make a huge difference in your cash flow and first pass recovery rate (FPRR).

1.  Tally your claims denials. I know this sounds like a daunting task, and in the beginning, it probably will be. But knowing why you are being denied is a great first step in correcting that behavior on the front end.

2.  As you are tallying the claims denials, you'll want to separate them by insurance class (Medicare, Blue Cross, Aetna, Cigna, Healthnet, etc.) If you have a total of 400 denials for the month and they are mostly PR-119 (went over insurance limit and is now patient responsibility), you really should know which insurance class this is happening with.

3. Once you have the denials separated by class and tallied by insurance denial type, now you can start to really drill down and find the mysteries of those denials. You will find a variety of denial types. I've found that almost half of claims denials are not really denials, but more of what I consider a "delay in payment." Take for instance a CO B11-Contractual Obligation. The claim/service has been transferred to the proper payer/processor for processing. The claim/service is not covered by this payer/processor. This means that the claims address or medical group provided to you at the time of verification was not provided or was incorrect. There is nothing for you to do but keep an eye on the claim to make sure the "correct payer" pays it.

If you get a denial such as CO197-Contractual Obligation Precertification / authorization / notification absent, this means that when the claim was submitted the authorization was omitted. This is what I would consider an "administrative mistake" and you will have to spend your practice's time to fix this.

By taking a step back and really understanding why you are getting denials, you can take the necessary steps to correct policies, procedures, and behaviors as far up as the front office and intake specialist. Your FPRR really should be higher than 90 percent every month, otherwise you are wasting precious resources on problems that could be avoided. Just remember, there is a time and place to add staff, but fixing the problems upfront will result in happier staff, and your bottom line will thank you as well.