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No pain, no gain–not true. 4 ways to deal with claims rejections pain

By Prime Care Tech Marketing on Thu, Feb 11, 2016 @ 02:00 PM


iStock_000045792732_Small.jpgMy office is in my home. Occasionally, my wife will step up behind my chair as I am working on the computer and start to massage the back of my neck. Ow! All of a sudden I am aware of a throbbing pain I didn’t know I had. At first it REALLY hurts. In a short time, though, I feel the pent-up tension and throbbing dissipate and I begin to relax. At that point she stops, giving me a reassuring pat on the back. Released, I return to my task, but then I feel the tension begin to return and I have to ask myself, “What’s causing this?” Likewise, sometimes providers get so caught up in the busy-ness of business, they are not aware of some persistent pains which can impact effectiveness and even the bottom line. 

Pain does not necessarily mean gain

One of those pervasive and overlooked pains involves claims rejections. Claims rejections require the billing staff to review the claims, address whatever is missing or in error and resubmit the claims in order to get paid. In some cases, payers reject specific claims over and over again. What’s even more painful is that billers, with the best of intentions, sometimes will put the rejected claims in a file folder which, if not dealt with immediately, can collect dust in some forgotten file drawer. Are you feeling the throb?

What can providers do to minimize the pain of rejected claims? Here are some tips you can follow to limit the number of claims rejections:

  1. Pay attention to them. Look at a summary of your rejected claims for the month and sort it by payer and rejection reasons. (In your clearinghouse application, you may be able run a rejection status report and sort by payer.) Do you see a pattern? Are the majority of the rejected claims coming from a few payers? Are the rejections for the same reason? Are the rejected claims submitted by one or two of your new billers? Are these legitimate rejections or do you sense that the payer is simply dragging its fiscal feet?
  1. Discover the issue and if it is something you can control, address and fix it quickly. There can be a lot of money at stake. In some cases, the payer implemented a policy change and will no longer accept a specific revenue code. Find out what that code is and make sure your billers use the correct code. This may require a focused review each month before submitting claims to that specific payer to make sure the new policies are followed. If you have a new biller on staff, the errors may be traced to him or her. This can be a great training opportunity.

    In some instances, we have discovered that a billing requirement may be published for all payers to implement. However, a few hold-outs still want providers to follow the old policy. Know who they are and make sure your billers know about them too.
  1. Check the contracts. Some payers will reject claims containing specific diagnosis codes. The problem may not be that the diagnosis code is not compliant with the ICD10 coding requirement. The payer just may not cover such diagnosis codes. We emphasize again – know your contracts. Having a code on the clinical record is appropriate, but may not be so on the claim. Avoid billing for excluded diagnosis codes.
  1. You may have to stop accepting certain insurances/payers. Do certain payers repeatedly reject initial claims submissions for no apparently legitimate reason? Opt out if the payer seems to be problematic. That’s a pain that may require contractual amputation.

No pain, no gain? In fact, in the case of rejected claims, you can gain without the pain by following these tips. Track your rejections and pay attention to trends in billing errors or payer practices. Then take corrective action immediately. Doing so can be as good as a neck massage, because…it makes cents.

Topics: claims rejections, billing staff

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