It seems payers these days are finding more and more reasons not to pay clinics in full for submitted claims. From non-covered services to ineligible diagnosis, these reasons for denied claims are varied and differ from payer to payer. What one payer will allow, another requires prior authorization. Administrators and managers must assure their staff know how to read, understand, track and correct denials. Staff must be able to read and clarify an explanation of benefits (EOB) and electronic remittance advice (ERA). 

Denial management is the act of managing the claim denials for a practice by determining their cause, correcting them, and putting plans into place to reduce their number. Staff must have the initiative and problem-solving skills to best handle these duties. Managers and administrators should encourage team members to question denials and find new workflows to assure they do not occur. Reporting denials reasons and trends to other teams within the clinic – reception, clinical, providers – will also help with this.

$25 to rework a claim? That is right, according to an MGMA Connection article it will cost the provider $25 on average to rework a claim. That might not sound like much, but think how many denied claims you receive every single day, month after month. So not only are you not getting money from the insurance company, you are having to pay $25 to rework it in the hopes that it will not get denied again. This is a cash flow nightmare for any practice. This is why we are writing our 5 tips to reduce denials. 5 simple improvements that can save you hundreds of thousands of dollars over the years. Without further ado:

Tip #1 Documentation Errors

in the fiscal year of 2013 CMS RAC auditors identified and corrected $3.75 billion in improper payments. Perhaps you were part of that, or perhaps you will be part of it this year, hopefully not! Simple documentation errors lead to poor coding which inevitably means either denied claims or low reimbursements. Think of this common error.