Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid


8 Tips for Avoiding Denials, Improving Claims Reimbursement

For many practices, reducing the denial of claims can put them on the path to improved claims reimbursement.

By Michelle Tohill of Bonafide

- If your practice is like most, your billing staff sees the words “CLAIM DENIED” fairly often, which not only leads to frustration and increased work but also reduced revenue for the practice over time.

Claim denials and claims reimbursement

A recent study by the American Medical Association found that medical practices spend almost $15,000 on the phone calls, investigative work, and claims appeals associated with reworking claims. This is in addition to the millions of dollars left on the table every single year due to under-reimbursement.

Medical billing is challenging, but there is no reason your practice can’t improve its reimbursement rates by minimizing claim denials and working every claim denial until it is resolved.

Here are a rundown of important activities in managing denied claims more effectively.

1. Automate everything you can

READ MORE: 3 Best Practices for Hospital Claim Denials Management

Keeping up with all the diagnostic codes and different insurance policies can be exhausting, but there are many software providers that will automatically update codes and requirements. This cuts down on your research time, allowing your billing team to spend more time double-checking claims to make sure they meet every single requirement.

Another benefit of automation is that software systems can streamline the documentation process and flag items that need to be resolved before claims are submitted. This means that your whole team can become aware of what needs to happen in order to get reimbursed, cutting down on the time the billing team needs to spend figuring out what is missing and tracking down the necessary parties.

2. Stay on top of changes

Even if you have software that will flag inaccuracies, your billing staff and everyone else in your practice should still be familiar with the general landscape of Medicare standards and the other payors. Your billing staff should keep up to date by subscribing to newsletters and attending conferences so that you won’t find your claims denied due to ignorance. Encourage your billing team to share important updates with the entire practice so that everyone stays up to date.

3. Do more up front

READ MORE: Top 4 Claims Denial Management Challenges Impacting Revenue

Most claims are denied due to minor details. Train your staff, your providers and everyone else who impacts billing to complete forms accurately, legibly, and without error. By taking care up front, you minimize agony on the back end.

4. Manage your team

In most billing departments, what doesn’t get measured, doesn’t get done. Therefore, it’s best to set your policies in stone up-front, and have a daily management system in place to ensure maximum reimbursement and minimize denials. Set up policies and procedures to ensure your team is carefully checking reimbursement requests before they are sent to payors. Track the claim denial rate, and set increasingly challenging goals to improve performance over time. A little bit of management goes a long way in minimizing claim denials.

5. Investigate causes of denials

If a claim is denied, your billing staff or service can’t just let it end there. Follow up is absolutely necessary in order to lessen the blow of claim denials. It may take some effort, but it’s well worth it to research the cause of procedure denials. You’d be surprised how many millions of dollars are left improperly reimbursed every year due to the fact that the billing staff didn’t properly investigate denied claims.

READ MORE: Patient Financial Responsibility Not Owed Top Medical Debt Issue

6. Work denials daily

Sometimes billing teams are so focused on daily new claims that they fail to re-work denied claims. Make it standard procedure for your team to work on denied claims every single day. Just because a claim was denied once does not mean it will be permanently denied. Your billers should be able to make the necessary adjustments and capture the reimbursement with attention and perseverance.

7. Check your work

When you’re dealing with a multitude of numbers and codes, there is always potential for error. And even the smallest mistake from your billers can cause a claim to be denied. Your billing team has to be hyper-vigilant to seek out errors before finalizing the claim submission. Check, check and recheck - it may seem like a lot of work up front, but the extra time could prevent unnecessary claim denials and the rework of already submitted claims, saving your practice time and money.

8. Don’t miss deadlines

With all the complexity in the billing arena, some denials are inevitable. But there is one type that is inexcusable, and that is a denial based on a failure to file in time. There is no recourse if you miss a deadline, and therefore the money is forever lost. Train your team and reinforce the rule that no claim should ever be late. You should have a 0% rate of denial based on untimely filing.

In every practice, maximizing reimbursement equals maximizing revenue. Without effective billing practices and the consistent attention to detail, your practice will experience a high rate of claim denials for all sorts of reasons. A well-managed billing team can single-handedly increase practice revenue significantly simply by avoiding and managing claim denials.

Michelle Tohill is Director of Revenue Cycle Management of Bonafide Management Systems and oversees all billing programs and processes. Her specialty is conducting AR audits to expose inefficient billing practices that fail to fully reimburse physicians for their work. She conducts AR audits and provides Bonafide customers with training and consulting on how to improve every aspect of billing and practice management to maximize revenue.


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