Terry's 4th of July Sparkling Spectacular of Tools and Techniques for Managing and Preventing Denials

When a claim is denied, it is important to understand the denial reasoning in order to effectively manage current claims and prevent future denials. It is crucial to proactively identify the root causes of your denials to prevent labor intensive analysis, research and resubmission.

Start by asking yourself these four questions:

1. What is causing our claim denials?
2. When do these mistakes occur in our practice?
3. Where is our practice most at risk?
4. How can we prevent claim denials from happening in our practice and manage them when they emerge?

Here are some of the most common reasons for claim denials and ways to avoid them:

1. Invalid insurance form - Prior to each patient appointment, verify insurance eligibility to be sure the patient is actually enrolled in the plan at the time of service. Upon check-in, obtain a photocopy of the patient's insurance card and accurately enter the information into the practice management system.

2. Invalid patient demographic information - Register patient prior to the visit and ensure that all demographic information is completed by the patient of or patient representative and correctly entered into the practice management system.
   

3. Provider information incorrect/invalid - It is essential that the provider's credentialing department confirms that all providers within the organization are credentialed and enrolled as a participating provider with the payer.
   

4. Invalid diagnosis/CPT code - Keep your charge tickets current with the latest updates of ICD-9/CPT codes.
   

   
   
   • Review medical records to verify the validity of diagnosis/procedure code.
   
   
   • Use current ICD-9/CPT references and resources.
   
   
   • Utilize the latest updates of automated coding software and/or a coding editor.
   
   

   
   
5. Referring physician information invalid/missing - Certain services, such as diagnostic or clinical laboratory test, require the submission of the ordering or referring physician's name and NPI number in items 17 and 17b of the 1500 HCFA claim form.
   

6. Referral/Authorization required - Strive to maintain up to date information on all policies and procedures related to referrals and authorizations for each payer.
   

   
   
   • Follow payer guidelines when submitting referrals/authorizations (via telephone, fax, submit attachment online, attach to paper claim or electronic data transaction) and enter the acquired information into the practice management system.

   
   
7. Duplicates - If you are signed up for automatic crossover for secondary claims, do not submit the claim manually or electronically since these claims are automatically sent to the secondary payer from the primary payer.
   

   
   
   • Research the claim to determine the details of the denial (true duplicate, maximum frequency, missing modifier, etc.).
   
   
   • Review the practice management system to verify duplicate entries of a service/procedure.
   
   
   • Pull data entry batches and examine encounter sheets to verify if an error was made by marking the service/procedure multiple times.
   
   
   • Review medical record, and if appropriate, add valid modifier to CPT code.
   
   
   • Use automated coding software and/or a coding editor to test for duplicate entries.

   
   
8. Documentation missing/needed - Required data is missing on the claim form.
   

   
   
   • Verify what data is needed by reviewing the remarks code on the explanation of benefits (EOB).
   
   
   • Correct, attach and resubmit claim electronically as a new claim.
   
   
   • Communicate to the appropriate staff and establish claim edits in your practice management system to ensure that corrections of these errors occur prior to claim submission.

   
   
9. Coordination of benefits - Verify insurance eligibility for both payers and determine primary/secondary sequence. Under certain circumstances you may need to use the active employment, birthday rule for dependents or dependent methodologies to determine insurance sequence.
   

10. Late filing/Filing time limit - Verify and understand payer's filing deadline.
    

    
    
    • Enter charges into the practice management system in a timely manner.
    
    
    • Follow up on claims with no payer response within 7-14 days of submission to make sure claim has been received by the payer.

    
    

These are just a few common reasons for denials. Denials for your practice may vary, but should be tracked to determine what types of denials your practice is experiencing.

Happy 4th of July!

Terry Fragoso
Vice President of Operations
http://www.thinkfirst.us/lower.php?url=terry-fragoso

Monica's Summer Cleaning Tips

The benefits of using a claims scrubbing software can tremendously reduce denial rates, shorten AR cycles and improve cash flow. With some tweaks, adjustments and updates you can maximize the effectiveness of your claims scrubbing software.


Here are my Top 10 Tips to Maximize Your Claims Scrubbing Software:

1. Stay current with the latest version of your claims scrubbing software - you may be missing out on many new enhancements!
   
2. If applicable, perform routine Local or National Coverage Determination (LCD/NCD) updates. Verify with your claims scrubbing vendor how often medical necessity policies are published for your state.


3. Implement routine CPT, ICD-9 and Correct Coding Initiatives (CCI) updates, ensuring CPT/ICD-9 validity.


4. Research if your claims scrubbing vendor publishes reports, training materials, newsletters and/or bulletins relating to application issues and updates.


5. It is crucial to inquire about and apply recommended database maintenance procedures (i.e. purges, size, speed, error messages, etc.) with your claims scrubbing software.


6. Discuss customization capabilities - it is important to create parameters (edits, payer specific rules, etc.) around unusual insurance specifications.


7. Generate and utilize standard and custom system reports regularly to assess and analyze how claims are being processed. These reports can be used to assist in training, education and tracking trends.


8. Consistently review your denials and appeals so that your claims process can become more streamlined. These findings will contribute to improved business decisions and help in modifying your claims scrubbing software.


9. Attend educational sessions offered by other organizations and users of the claims scrubbing software (user groups, conferences, seminars, webinars, etc.).


10. Finally -- never underestimate the power of tapping into your internal knowledge base! Create an internal team to make your claims editing software more efficient and valuable.

End Result = Clean Claims = Priceless!

Monica Stovall, Senior Consultant, Think First
http://www.thinkfirst.us/lower.php?url=monica-stovall