According to the California Nurses Association, insurance carriers deny 1 out of every 4 medical claims submitted. This means that without further investigation, only 75% of all medical claims generated will be processed by the carrier. A 25% denial rate is alarming to consider when most healthcare practices submit legitimate medical claims for services already provided to the patients. Increasing denial rates are an important and unpredictable financial drain on healthcare providers, which means that studying these denials is key to getting properly reimbursed.
Even legitimate claims can be denied so it is important that you investigate every denial in depth: Every unpaid claim needs to be investigated in detail so that healthcare providers can uncover consistent trends by one or even several insurance carriers. Some submitted claims may be 100% legitimate and still be denied as it is in the carrier’s best interest to not pay out every claim that comes in.
Some carriers even expect some healthcare practices to never look at their denied claims: If the insurance carrier expects some healthcare practices to not make any effort to look through their denied claims, then they will deny more claims than necessary to benefit financially from their carelessness. This is why it is not enough to simply investigate the reason for the denial. It is important to study the trend as a whole so that more comprehensive measures can be taken to prevent legitimate claims from slipping through the cracks. Also if there is a flaw in the medical billing process that is causing these denials, it needs to be weeded out before significant losses can be incurred.
Implementing a standardized appeals process is critical to streamlining medical coding and billing: Once the claims have been analyzed and the trend unearthed, it is important to put an appeals process in place that is in keeping with the appeals process outlined in the provider contract. Having a standardized system in place to handle claims that are being appealed means that you have a consistent way to track and manage these appeals. That way, you can rest assured that human error does not factor into getting complete reimbursement from the insurance carrier when it is owed.
Allowing these delinquent claims to pile up because dealing with the appeals process can be frustrating is not a good enough reason to tackle them later. These claims can have a significant impact on the revenues of the healthcare provider. That is why it is vital that the medical practice deal with them as soon as they are received. A standardized process will help healthcare providers tackle denied claims the second they are received so that no unnecessary delays occur in the appeals process.
Because the appeals process can be long and require a lot of following up with the insurance carrier, a streamlined and automated system should be put in place. This way, minimal effort is exerted in getting properly paid for what is legitimately owed to the healthcare practice at all times.
By studying delinquent claims and developing a streamlined system through which they can properly appeal the denial, medical practices can make their medical billing and coding process more effective. Studying the different reasons for a claim denial will also help the healthcare practice identify critical ambiguities or loopholes in their system that need to be resolved so that they can ensure greater reimbursement rates overall.
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