Let’s face it… dealing with denied claims makes most people want to scream! Not only can it result in lost time and increased frustrations for both the employee and patient alike but it can also be costly to the organization. So what is the impact to the organization when claims are denied? Some of the biggest impacts denials can have on your organization include:
- Hospitals and physicians having their payment delayed, or not getting paid at all
- Frustration from the patients
- Unnecessary time and costs involved in researching the denial and learning how to begin the appeal process
- Decreased productivity within the Registration/Billing staff
Claims can be denied for an endless number of reasons but there are some reasons that seem to creep up more than others. Below are some of the most common reasons according to the AMA’s National Health Insurer Report Card:
- Non-covered charges and procedures
- Referral or preauthorization was required
- Out-of-network providers
- Data entry errors
- Wrong insurance company gets billed
- Patient is no longer enrolled
In case processing claims was not complicated enough, certain insurance providers require additional information or information filed in a very specific way in order to successfully process a claim. Some common examples of this include:
- Patient and Subscriber names do not match. (Medicare)
- Invalid Recipient ID Format (Florida Medicaid)
- Required CPT Codes when filing a claim. (Commercial, Medicaid, Medicare)
- Patient type. Certain procedures only applicable for Inpatient/Outpatient. (Commercial, Medicaid, Medicare)
- Incorrect Payer (Medicare, Medicaid)
- Covered Days for Patient Status (Medicare)
- Subscriber ID & Group Number Mismatch (Commercial, Medicaid, Medicare)
- Invalid Patient Zip Code – Last 4 digits (Commercial, Medicaid, Medicare)
- Invalid Admission Source (Commercial, Medicaid, Medicare)
- ICD9 Procedure Code Not allowed on Outpatient Claim (Commercial, Medicaid, Medicare)
- Invalid Date of Service (Commercial, Medicaid, Medicare)
- Too many ‘Condition Related To’ Codes (Current max of 2) (Commercial, Medicaid, Medicare)
Do not lose hope though!!! Although the world of insurance payers and claims can be frustrating, there are a number of ways in which organizations can minimize claim denials, increase both employee and patient satisfaction, and save money! Below are some best practices to consider that can have a huge impact on your success with processing claims.
Verifying Insurance Information through Automation
One way of minimizing claim denials is to verify that the subscriber listed under the patient account has active coverage at the point of registration. There are many ways of accomplishing this to maximize efficiency of the registrars and cut down registration times:
- Utilize third party programs that can scrape the information from the insurance screen and initiate an insurance verification. Many of these programs can let you know within 20 seconds whether or not that subscriber has active coverage. You can also have the option of automatically inserting the discrepancies right back into MEDITECH real-time.
- Pro: Much faster than manually calling the insurance company. Catch the errors that may be present in the patient account, such as DOB, policy number, etc.
- Con: Can add some time to the registration process if the site does not typically verify benefits at the point of registration.
- Utilize third party programs that allow you to batch up prescheduled visits or visits that have occurred recently to verify all at once. That information can then be sent to a scripting engine to enter into MEDITECH on an hourly or daily basis.
- Pro: Cut down the registration process without sacrificing assurances that the insurance is valid and subscriber information is correct for that patient.
- Con: This does not occur real-time, so there is not the added benefit of the registrar being able to pick and choose which information gets passed over to MEDITECH on a patient by patient basis.
Share information between the ADM and B/AR modules
Each version of MEDITECH has a place to enter notes from the visit registration. Those notes will be transferred over to the individuals in the billing department. By capturing certain information from a trusted system you could decrease the time it takes for the billing department to get the bills out the door as well as cut down the number of returns. This information should include:
- Date of insurance verification
- Verification status
- Copay, deductible and deductible met information
- Address updates (while retaining the changed address)
Creating work-flow processes through common MEDITECH fields
Each version of MEDITECH Magic, Client Server and 6.x have built-in fields to capture insurance status information. Work flows can be built around these statuses to ensure accuracy prior to claims being made. As an example, the Eligibility Status field contains information on whether that insurance has been Verified, Queued, Pending, Received, Failed, Denied or Deferred. It also contains a field for on what date the status has changed and whether or not it was checked electronically. By utilizing these fields you can quickly determine what status that insurance is in to create a custom work flow. Examples include:
- Blank -> Pending at the point of registration.
- Received -> Verified by the quality assurance team.
- Verified ->Completed.
By utilizing these methods one can have confidence that by the time the status enters a “verified” state all has been done to minimize claim rejection.
Capturing full benefit information at the point of Registration
When calling for pre-authorization or calling to verify benefit information it is not practical to collect the full benefit information for any given insurance. Even if you did, where would you put it?
Many of the third party vendors that verify insurance information can pull the different benefit information for all patient types in a single verification request. A hospital can create a custom-defined screen to store this information that will follow the visit. This would allow for all benefit data to be present within the visit at the initial point of registration so that the patient will know immediately what they can expect to pay for their visit. By taking advantage of MEDITECH’s custom-defined screen capabilities the benefit data can be captured at either the insurance level or at the visit level.
Capturing Subscriber, Patient and Guarantor demographic information at the point of registration
Even when you have collected all of the eligibility information for the patient and verified that the correct information is in MEDITECH, the bill still has to go out to the patient. It is best practice to always verify that the demographic information for the Patient, Guarantor and Subscriber is up to date. Along with insurance verification there are many third party vendors that allow you to verify that address versus USPS or even some of the leading credit bureaus to confirm that the address is valid. Couple that with a scripting solution and you now have a way to correct simple address mistakes that could cause a bill to be returned. Some of these causes include:
- Incorrect street name suffix (DR instead of ST)
- ZIP code + 4 missing
- Old patient address
- PO Box listed on the wrong line in MEDITECH (LINE 1 versus LINE 2)
Verify future dates of service with MEDITECH 6.1
For inpatients, verifying that the patient will be eligible for services in a future date can be tricky. MEDITECH 6.1 allows you to verify insurances for multiple effective dates to ensure that next week or next month the patient will still be covered with his or her current insurance.
Through automation, this could allow a hospital to identify all current patients a few days or even weeks before their estimated discharge date to have their insurances verified. Each instance of verification can be stored within the system to ensure that the hospital will be collecting the amount they have planned on collecting for that patient’s stay.
Just imagine a world where more claims are approved up front! Employees could rest easier knowing that patients are happier and they are helping save time and money. The above best practices are just a few ways in which organizations can help reach this goal!
I hope you have enjoyed this blog and please stay tuned to the IPeople blogs for more techie tips and tricks to get you flying through your work as well as much more educational information.