Dealing With Credit Claim Denials: Strategies From Kansas Attorneys – You submit a patient’s claim to their insurance carrier, they review it, and they pay you. Quite simple, right?
As far as the process of submitting a claim is concerned, it is definitely not easy. Any experienced medical biller will tell you that the three steps I just listed require much more and that it is the details that matter most in each step.
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Regardless of how a particular claim is denied, they all go through the same overarching process once they are received by the payer: adjudication.
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Even if your company doesn’t have complete control over the claims process, there are workflows you can set up now to improve your chances of getting paid.
In short, claims adjudication is the process that each insurance payer goes through to determine how much they owe a provider based on a claim they receive.
The ideal scenario for the healthcare organization that submitted the claim is that the payer decides to pay the full amount. In this case, the healthcare facility will be credited the full amount to its bank account.
In some cases, a payer will decide that it will only pay back a portion of what it owes to the healthcare organization according to the claim. This scenario occurs when the payer determines that the billed level of service is not appropriate based on the diagnosis or procedure codes. When that happens, it’s a disappointing situation, but at least there is SOME form of compensation.
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By far the worst scenario that can occur as a result of a claims decision is a denial. Rejections occur when a submission contains obvious errors. In the event of a rejection, the payer returns the application to the healthcare organization that submitted it along with a reason for the rejection. Unfortunately, payers do not provide compensation for denials until they are resolved and resubmitted (more on that later).
Just like the Electronic Data Interchange (EDI) registration process, the claims decision looks different for each payer.
The flowchart above is from Oracle Health Insurance. This payer has an entire webpage dedicated to explaining its decision-making process.
As you can see from the flowchart, the process is pretty simple, right? I’m being facetious. It’s great that Oracle Health Insurance took the time to create a flowchart that graphically explains the claim settlement process, but it’s definitely not easy to understand.
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The takeaway from this flowchart for the payer is essentially that you submit the claim and they perform a series of checks and balances against the associated plan.
The graphic looks good, but isn’t particularly helpful. Let’s break down the steps most payers take during the legal process.
The first step in the decision-making process is the initial processing review. Believe it or not, this is where many claims end in rejection.
In this first step, the payer checks the claim for simple errors or omissions. More specifically, payers pay attention to the accuracy of…
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If an application fails this step, it will be returned to the organization that submitted it. Of course, that means it gets “denied” status. Rejections aren’t the end of the world because you can resubmit them. But revising and resubmitting costs company resources.
The automatic review step examines in more detail whether the claim complies with the payer’s policies. More specifically, this step checks whether…
The third step is to have a trained, professional medical claims examiner step into the spotlight. In some cases, the examiner may also bring in a nurse or doctor to review the claim as well.
In any case, most payers tend to agree that this is a necessary guardrail for the process. It is not uncommon for a request for a medical record to be made at this step. Requests of this type are not made every time, usually only for procedures not listed to determine medical necessity.
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The final two steps within the standardized decision-making process occur only after a claim has passed the three phases of review. In other words, this is how healthcare organizations receive payments from payers.
Before we go any further, I have to confess something to you… In court proceedings, receiving money from a payer is not referred to as “payment.” The payment as a result of the claims decision is referred to as either a transfer notice or a payment declaration.
Money. In addition to the money or credit associated with the claim, explanations are also included. These explanations provide information about the reasons for…
Of course, this is my easier-to-understand explanation. More specifically, these reasons come in the form of the following key data points:
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Of all the payment determination statuses a claim can receive during a payer’s adjudication process, “rejected” is the most frustrating.
Remember at the start of this blog post when I stated that 30% of all claims are denied? I wouldn’t have included this statistic in the introduction if it wasn’t one of the biggest pain points healthcare organizations struggle with when dealing with payers.
Because if a claim does not pass all checks during a payer’s adjudication process, it will be returned to the organization that originally submitted it with a status of “rejected.”
To put it bluntly, a denied claim means the insurance carrier won’t pay you for services you provided to a patient.
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In addition to the payer not receiving payment, denials also require organizational resources to revise and resubmit the claim as an appeal. Therefore, accepting a complaint ultimately costs the organization more than the original filing.
The clear argument against this is the saying “money is money”. But the better answer is that establishing accurate workflows for submitting claims AND filing appeals reduces all operational costs.
Essentially, clearinghouses take the burden off healthcare organizations’ shoulders by pre-screening all claims before they are submitted.
I’ve already pointed this out, but each payer has different EDI registration and assessment requirements. Additionally, most patients served by healthcare organizations will use different insurance carriers.
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Clearinghouses already have established connections with thousands of payers (we have these). In other words, registering with the right clearinghouse immediately relieves the healthcare organization of these tedious tasks.
Because clearinghouses inherently understand what the arbitration process needs for thousands of payers because they are affiliated with them, part of their added value is in claims settlement.
Claims settlement is the process by which a claim is submitted to the clearinghouse BEFORE the payer. In this case, the clearing house compares the claim with the payer’s requirements and provides feedback on this.
The claim cleanup is done as a “spell check” function. The clearinghouse points out any errors before making a decision on the payer so that the healthcare organization does not face rejection.
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Obviously, many processes occur during the claims process that are beyond the control of the filing healthcare organization.
The only form of “control” the healthcare organization has after submitting a claim to a payer is to ensure that it is 100% accurate BEFORE submission occurs.
However, some clearinghouses (like ours) offer healthcare organizations the opportunity to gain insight into the status of their application submission.
Determining the status of a claim makes it easier for the healthcare organization to predict its revenue more quickly. If the organization checks the status of its submitted claim and it doesn’t look good, it can also preemptively initiate its appeal process.
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Of course, nothing is as easy as it sounds when it comes to working with insurance payers. Deciding the claims process is no different.
In the industry, adjudication is the internal process that payers go through to determine whether or not to reimburse the organization that submitted the claim.
When it comes to one of the most tedious processes in the revenue cycle, it’s definitely one of the top contenders… especially because much of it is outside of the submitting organization’s control.
However, working with a clearinghouse (e.g.) makes decision-making easier by streamlining front-end processes and providing visibility into the status of each claim submitted. Accurate patient data collection is perhaps one of the most undervalued processes in the revenue cycle process chain. The data collected during demographic mapping not only forms the basis of the medical record, but also impacts the payment of insurance claims. The error-free recording of patient data is essential for a clean application submission and makes it easier for the cost bearers to process the application quickly.
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The front office at the point of service should accurately record patient information, either through paper-based registration processes or through the appointment scheduling system. Accurate patient information is critical to determining patient eligibility and benefits, obtaining prior authorization, and accurately submitting claims. Furthermore, population health analysis is only possible through the use of accurate patient information.
At Medical Billing Wholesalers, we have trained our team of revenue cycle experts to validate all information available in the face sheets. Our team will contact the provider’s office or medical billing company if information is incomplete, inaccurate, or there is a discrepancy. Our team members enter the validated data into the client’s practice management software with a high level of security
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