9 tips to reduce denied claims
When it comes to avoiding claim denials, training staff to understand payer policies and regulatory requirements is critical.
When it comes to avoiding claim denials, training staff to understand payer policies and regulatory requirements is critical.
“Being smarter than your payers is the key to successful denial management,” says Michael Strong, CPC, bill review technical specialist at SFM Mutual Insurance Company in Bloomington, Minn.
Consider these tips to ease the appeal process:
1. Provide payer-specific training for billing staff members
Develop this training internally, or work with a local consultant who can incorporate the practice’s denial trends and payer audit trends.
Why it helps: Reduces denials related to prior authorization and medical necessity.
2. Boost staff confidence
Help billing staff view themselves as patient advocates who contribute to patient care.
Why it helps: Reduces denials related to data entry.
3. Build a relationship with the clearinghouse
Ask billing staff to contact the clearinghouse to obtain information about what’s denied in the local region for the same specialty. Most clearinghouses can provide this information-it’s just a matter of scrubbing and disseminating the data. The same is true for practice management vendors.
Why it helps: This data can be more specific than the denial remark codes that payers provide, and it can help practices address denials proactively.
4. Reality check: Denials are inevitable
It’s impossible to avoid denials entirely, so your practice must be prepared to respond to claim denials and appeal them as necessary.
Here are tips for appealing a denied claim:
Give payers what they want
“Look at the remark codes, and address those specific edits,” says Strong.
Avoid missing information
Missing information is a common reason for claim denials. Payers often look for lab or operative reports and won’t pay the claim until they receive this documentation.
Ask for exceptions
Policies aren’t set in stone, and payers may be willing to make exceptions for diagnostic procedures such as labs or x-rays when patients have an abnormal or uncommon presentation, says Tammy Tipton, owner of Appeal Solutions Inc. in Oklahoma City, Okla.
For example, many clinical guidelines are more applicable to adult patients and may not be relevant to pediatric patients.
Use external review options
The ACA expanded access to external reviews-something that payers don’t necessarily want providers to know, Tipton says.
- Providers who are authorized to appeal on a patient’s behalf can request an external review after they’ve exhausted all internal reviews with a payer.
- Providers can obtain this authorization by asking patients to sign an assignment of benefits and authorization release, including the ability to pursue appeals on the patient’s behalf.
9. Cite ERISA in external reviews
Be prepared to cite the Employee Retirement Income Security Act (ERISA). ERISA allows providers with authorization to appeal on a patient’s behalf to:
- Ask for the specific internal criteria on which a payer is basing a denial.
- Ask the payer to provide the credentials of the reviewer. Physicians can demand peer review.
- File appeals within 180 days. This may go beyond a payer contract allowing only 30 or 60 days, says Tipton.
