A lot of issues are faced by healthcare organizations in the process of revenue cycle management and they need a robust system in place to tackle these issues effectively. All the various issues related to operations, communication, and finances have to be managed carefully or else healthcare providers may suffer the loss of revenue. To mitigate such losses, healthcare providers need to employ the best RCM services providers who implement best practices in revenue cycle management with the highest levels of efficiency.
One of the significant factors in the inefficient management of the revenue cycle of healthcare facilities is claims denials. Here are some tips to act proactively regarding the claim denials to get timely reimbursement for the claims submitted and have a healthy revenue cycle.
Claims denied due to medical reasons: Often the claims are denied showing the reason as medically unnecessary or incomplete medical notes. To eliminate chances of such denials, the RCM services professionals should proactively ensure that the procedures being provided are totally covered by insurance. It is also noticed that some of the denials are due to registration errors and incomplete information which can be easily eliminated by cross-checking the information at the time of registration.
Claims denied due to eligibility issues: To ensure that the healthcare providers don’t suffer any losses due to claims denied on the basis of eligibility, the RCM services professionals along with the front-end and administrative staff of the facility should capture accurate demographic information about the patient and perform the eligibility verification even before the patient is provided treatment. To enable proper settlement of the claims, coverage should be double-checked for both primary and secondary payers and the percentage of co-insurance if any. Lastly and very importantly, it should be verified proactively if the treatment procedures are not excluded from the insurance coverage and there are any limitations to the patient’s policy.
Claims denied for mismatch in codes: Medical coders and billers should ensure that during the coding and charge entry processes the CPT AND ICD codes are aptly entered and an audit is conducted on a regular basis prior to sending the bills for claims rather than working on these matters later when a claim is denied.
Claims denied due to filing outside timeframe: Billers should be aware of the various insurance payers’ guidelines, rules and their timelines with respect to payments so as to send the claims on time and avoid denials due to late filing. For this, billers ought to have great time- management skills and streamline their processes with appropriate tracking and reporting systems in place.
Claims denied due to duplication: To avoid claims denials citing duplication as a reason, the RCM services experts should verify all the entries before submission of bills for any duplicate entries and ensure modifiers are not repeated.
In the complex healthcare industry, claims denials are an integral part of the revenue cycle and they cannot be done away with so easily. Moreover, all the denial issues faced by healthcare providers are not similar and hence common solutions to fix these issues cannot be worked out. However, by employing the right RCM services providers, the losses can be mitigated to a great extent.