3 min read

How to Handle Claims Rejections

By Prime Care Tech Marketing on Tue, Nov 03, 2015 @ 05:53 PM

ClaimsNo one likes rejection - neither an amorous suitor, an eager job seeker, nor a presidential aspirant. But when it comes to love, employment, politics, or money, well, no pun intended, money trumps them all. And the root to your positive cash flow lies squarely in your ability to collect the revenue owed. Most provider revenue comes from third-party payers through the medium of claims. But occasionally, notwithstanding their best efforts to submit clean claims, providers may receive rejections due to undiscovered errors. The key is to turn those rejections into payments - quickly. Here are a few tips to consider and to implement

How do providers receive rejections?

The answer should be obvious, but it is worth mentioning.

Paper-based claims – In those instances where providers must submit paper claims, a rejection may come in the form of an Explanation of Benefits (EOB) or letter. This is obviously the least preferable way to submit claims, but providers may not have a choice, depending on the payers. So here is the possible trap. Payers have front-end scrubbers used to detect errors. This takes place before the claims proceed to the adjudication system. Because this occurs up front, payers will likely not have a record of the claims scrubbed. So if a biller calls about the status of a claim, the payer’s customer support person may not even find the claim. When providers do receive rejection notices, these documents will describe what needs to be corrected.

Electronic claims – Most claims clearinghouses have portals which allow you to easily identify rejected claims. In that view, billers can identify rejected claims and take action to correct them and resubmit the claim within the portal

Tip: Where possible, file claims electronically. When not possible, carefully scrutinize the remittance advice when you receive it

The importance of timely responses

We cannot stress enough the need for providers to respond to the rejections as soon as possible. To fail to do so will not only result in payment delays, but possibly in no payment at all. Providers have established timely filing limits ranging from 90 days to 18 months. Should a provider fail to respond to the rejection within that time frame, well, that’s too bad. It becomes a likely bad debt write-off

Tip: Pay attention to the aging every month. Following up sooner than later is prudent, because it is easier to track down what information you need now than it would be later

Most common reasons for rejections

Some of the most common reasons for rejections, more than likely resulting from input errors or having the incorrect information in the first place, include the wrong payer ID number, member ID number, the wrong date of birth, a misspelled name, etc. Even claims clearinghouses may miss these errors

Tip: Identify the most common potential errors and include them in the triple check process “script”.

Documentation needed to correct errors

The biggest problem our team has observed over the years involves the preadmission and admission processes. Obtaining vital information ahead of time with the necessary documentation in hand is critical to verifying correct name spelling, DOB, address, member numbers, verifying primary and secondary payers, etc.

How a clearinghouse can help

Using a clearinghouse to submit claims gives providers several advantages.

  • A clearinghouse typically has the ability to scrub claims and catch errors BEFORE submission to the payers.

  • A clearinghouse can display claims rejections which providers can view and correct.

  • A clearinghouse constantly checks for updates to new payer-specific requirements, such as new codes, eligibility requirements, etc.

The bottom line to avoiding the fiscal pains of rejection is to constantly monitor for them and to respond quickly with the correct information. Identify the most frequent causes of rejection and include them in your claims triple check process.

It only makes cents.  

Claims Process