According to the Medical Group Management Association, high-performing medical groups have a four percent claims denial rate. If your denial rate is over 4%, don’t blame your payers; instead, look at your business’s processes. Timing problems, manual mistakes, and input oversights may be causing most of the denials. 

Something you could do before submitting claims to make sure they're clean is ask yourself the following questions! Clean claims = less denaisl. Print them out and post them to your bulletin board!  

Monitor these five issues to improve your billing approach and decrease your denial rate.

1.    Is the Claim Legible?

Although most payers accept claims electronically, a few individuals will still use paper submissions (now THAT is old school).  If you only focus on electronic claims, the paper submissions won’t get enough attention. Illegible and messy printed claims are common, which can be problematic for payers who scan the claims into a system.

2.    Is the Claim Specific Enough?

If your coding is at the highest level of specificity, you will reduce your denials (I know what you’re thinking – well, duh).  This means that the greatest number of digits for the code must be used. If you have a code that has four-digits that requires five digits to be accepted, you will get a denial if you send off four digits.

3.    Is the Claim Missing Information?

Your staff shouldn’t leave specific encounter data off the claim because it may cause an insurance denial.

A payer who is detail-oriented will pay attention to omissions and will count errors as a reason to deny a claim.  According to the Ohio State Medical Association, the most common missing information are date specifics, such as date of medical emergency, date of accidents, and date of onset.

Ensure that your employees fill out every required area on the claim forms.  The individuals who are billed must double check the patient subscriber number and the commonly missed fields (I didn’t say some of these wouldn’t be common sense).

4.    Is the Claim Up To Certain Standards?

Some payers could be more sensitive to certain claim issues than others.  Although each claim should be error-free when it’s shipped, understanding which payers are picky can help you send those individuals the most flawless claims.

5.    Is the Claim Filed On Time?

The most frustrating denial is a timely filing denial.  Each payer operates on a specific deadline schedule, missing the timing window is possible if you are not careful.  So, keep a list of your payer deadlines nearby.  It may help to track and document every payer’s receipt, when possible.

Claims are unfairly denied sometimes for timely filing.  This occurs when a claim is submitted correctly, but the insurance carrier didn’t receive it within the window.  You should hold the payer accountable for timely receipt of the transactions.

Claim was denied… now what?

You should appeal the claim.  According to the MGMA, only 35% of providers appeal their claims.  Also, ensure that each denied claim is correct and develop a management system in your company.  You should give an employee appeal duties.  If these procedures are not used, four percent of the money will slip through cracks.

Group your transactions. This helps pinpoint which insurers are always denying your claims.  Ensure that every claim that is submitted to your most finicky partners are very precise and clear.

Monitor your claims submission reports - doing so can reduce denials and delays.  If you can’t tackle this task, let someone on your staff handle it.  When you send a claim from your practice system, you should get two reports.  Review both reports immediately because they offer an explanation of benefits, which can help you determine the reason for the denial.  Also, every quarter, you should review your payment report to ensure that you are paid properly because they sometimes overpay or underpay.  This is why practice managers must keep a fee schedule for every carrier close by.