Claim denials are the bane of every RCM company. Chasing money is costly and navigating regulations, coding edits, and health plan particularities can frustrate even seasoned billing professionals.
The American Association of Family Physicians puts the average claim denial rate at around 20 percent and reworking a single claim can cost hospitals and offices anywhere from $25 – $118 on average, so the initial validity of every claim is critical. While denial percentages have been dropping – thanks to technology that allows billers and coders to verify accuracy of their work and catch the most egregious errors – the reality is you can do better. Use the following seven tips as a starting point to determine how you can maximize revenue by reducing denials.
Recognize that the revenue cycle begins in the front office.
Providing services to patients whose insurance has changed or lapsed will result in a denial—even if it’s coded correctly. Make it a point to check your patients’ insurance at each visit, including copays and deductibles. Front-end verification can prevent back-office headaches.
Look beyond first-pass clean claim rate.
A high first-pass clean claim rate may look great on the month-end statement you provide to your bosses, but what does it really mean? This rather meaningless metric only gauges the percentage of claims that are initially accepted by a payer. It says nothing about the denial rate, which is where the real work begins. Focus on metrics that matter, such as denial rate, collections as a percentage of revenue, or days in A/R.
Learn from your mistakes.
Use denied claims as a learning experience. Why did the claim deny? Some common reasons include a lack of medical necessity, a mismatch of diagnosis and treatment codes, upcoding or unbundling, incorrect coding, and missing/wrong modifiers. Use claim data content with comprehensive edit logic to perform a deep dive into denials. Is the problem an individual coder, clinician documentation, or a certain procedure or treatment type? Understanding the “why” behind every error will help you uncover how the organization can do better.
Examine your workflows.
Your increased denial rate may be occurring because your operational workflows aren’t aligned with billing best practices. If you are performing claim editing only after the claim is generated, you’re not allowing for actionable change by those who created the errors. Also, are those who work denied claims relaying the information back to the relevant department? If your billers, coders, and clinicians don’t know they are making mistakes, they will continue to make them
Edit claims early in the process.
This goes hand in hand with our previous step. Recognize that revenue cycle management truly begins in the front office and flows through everyone who generates a charge, codes a procedure, or prepares a claim. Develop the mindset that everyone who touches a patient record should understand the implications of coding. For example, a clinician who sees charting as a burdensome task may make inadvertent mistakes that results in incorrect coding, which in turn creates more work for your billing staff who has to work the denial. Fixing these costly mistakes takes precious time that would be better spent on more complex tasks.
Examine your claims technology.
Claim editing software is a must to reduce denials. But not all software is the same. As we said before, claims acceptance is important but has little bearing on overall denial rates. Many electronic medical records and practice management systems have generic claim edits that check for obvious technical mismatches such as age-related discrepancies, date of service issues, and CCI mismatches. But those systems will do nothing to help your billing department move the needle on denials. An advanced clinical claim editing solution with constantly updated content is worth the investment. The edit explanations help your coding staff recognize the changing parameters that can affect denials.
Train for better performance.
Not everyone on your staff or in your billing organization needs to understand coding and claims at a detailed level. However, everyone should understand the role they play in the revenue cycle process. Don’t simply demand that front office staff check insurance every time – explain why it’s important to the claims process. Make sure clinicians understand the differences between common visit types and procedures so charges are captured accurately on the front end. And ensure your coding and revenue cycle personnel are working to add value to the organization by performing high-level work. A robust clinical coding and claim editing software can help educate coders on procedural changes and provide tips to keep claim denials as low as possible.
Just as everyone who interacts with a patient affects that patient’s perception of your practice, reducing your organization’s claims denial rate is the responsibility of every staff member who interacts with the patient’s data. Ensuring accuracy throughout your entire revenue cycle will improve the overall integrity and result in improved revenue.
The Alpha II Solution
Are you ready to submit precise claims the first time? Contact Alpha II, a leader in revenue cycle solutions. Our comprehensive clinical claim editing solution, ClaimStaker, covers the entire continuum of care, verifying claim data from the payer’s perspective and allowing for corrections prior to filing.
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EZClaim Reports – Written by Stephanie Cremeans of EZClaim
Have you ever gone to leave for a meeting, you’re right on schedule or maybe even a couple of minutes early, you go to grab your keys – but they aren’t where they are supposed to be. You feel a mild wave of stress, ok … if they aren’t here they have to be in my jacket pocket. You reach in, nope – no keys. Now the stress turns to a sense of urgency, you have to leave, right now, but where are the keys? You start running through every possible place you may have stashed them – you dart from here to there, back and forth until you finally stop yourself. You take a second to calm yourself and retrace steps, you have your “a-ha” moment and walk directly to your keys.
If you are a report user – chances are you’ve experienced a similar scenario when you run your daily, weekly or the dreaded month-end reports when something seems off. Report users depend on the integrity of their reports, they are the key to making decisions, tracking productivity and understanding the overall health of the practice. Running a report that “just isn’t right” brings about the same feeling of losing your keys when it’s time to walk out the door. Much like the scenario above, you grasp at straws to figure out what went wrong – but it seems that report problems escalate the stress levels at warp speed! Next time that a report seems “wrong” try to stop yourself from diving into panic mode and take a minute to consider some logical problems that may be throwing those reports off. Yes, some of these suggestions seem so obvious, but just like the lost keys – we can miss the obvious when we are missing something so important.
Start by making sure that you are running the correct report:
Are you comparing numbers from a previous period? If so, make sure you’re running the same report with the exact same criteria as the one which you are comparing.
What are you doing with the report? Is this for compiling information, is this a work tool? The answer may make a difference when looking for the correct report, in EZClaim a customized grid may even work better than a predefined report.
Check your dates:
Check the dates of the criteria you are using – is your data to be compiled by a transaction date, created date, exported date? Are your dates too wide open or too limited?
Do you have transactions entered with incorrect dates? Future dates or a transposed number such as 2002 rather than 2020 can be overlooked, but cause problems with reporting.
Consider factors within the practice that would affect a big fluctuation for the period in question:
Were there providers on vacation or a holiday that affected practice volume?
Are there outstanding credentialing or enrollment issues that would have slowed or stopped payments?
If you don’t have a set of reports that you monitor, I highly recommend that you consider making this a priority in 2020. Watching specific data sets, or key performance indicators gives you the information you need to spot a problem before it is out of control. You can monitor provider and billing productivity easily, making sure your revenue is being collected in a timely manner. EZClaim provides several reports and customizable grids that can give you the details you need, right at your fingertips.
If you have ever been the victim of poor customer service you know how frustrating it can be. Long wait times, scripted answers, limited product knowledge, poor communication skills, and ultimately unresolved problems. No matter how good the product is, poor medical billing customer service leaves you feeling alone and stuck teaching yourself. At the end of the day, it’s an experience that we at EZClaim are committed to solving and have been since the company was founded.
What is it that EZClaim is doing that sets us apart and makes your experience better than the status quo?
There are 5 Keys to Customer Service we have built into the fabric of EZClaim.
1. CREATE A CUSTOMER SERVICE CULTURE: We take pride in saying, ‘we’re a customer support company that happens to sell software’. This means we put our support team first, we listen to what they’re reporting back, we celebrate their successes and focus on fixing the problems they highlight and in the end that makes both a great product and a great experience.
2. HIRE INDUSTRY EXPERTS: We aim to hire experts with industry experience that understand your challenges in medical billing, coding, and working with healthcare practices. This ensures that you are speaking to someone who knows your needs and can provide solutions customized to you.
3. CREATE A STRONG FOUNDATION: We have learned that the best way to solve problems is to create a solid foundation of understanding upfront. To do so we developed an onboarding-discovery process where we learn about your practice, the way you do business, your pain points and your overall needs. Based on that we work with you through training to set up the system that best works for you.
4. RESPOND QUICKLY AND FOLLOW-UP CONSISTENTLY: We have made it a priority to respond to your needs immediately. With a 100% U.S. based support team our average response time is within 1-2 hours of your request. We know your business and the services you provide are important to you, and responding quickly to your needs is important to us.
5. MAINTAIN RELATIONSHIPS FOR THE LONG-TERM: Finally, our customer service is designed to maintain our relationship for the long-term. We want the experience to be smooth, the follow up to be consistent, and most importantly we want you to know we care. To prove it our contracts are month to month, so we know that each month we have work to provide the best service available to you.
Finally, we know some people work best when they work things out on their own. We have a full library of YouTube tutorials and comprehensive online manuals to help you problem-solve. We do this and more because we celebrate our customers, we work hard to be here for you when you need us most, and we hope you’ll consider EZClaim for your medical billing software needs.
Live Compliance – EZClaim’s trusted HIPAA Compliance Experts
It is often, small companies who work in healthcare falsely assume that HIPAA pertains to large organizations and hospitals, when in fact, a Business Associate, is a person or entity that works with Protected Health Information. Many organizations don’t realize that the fundamentals of a compliance program are Business Associate Agreements, and performing Security Risk Assessments.
In fact, an Indiana-based Business Associate, Medical Informatics Engineering, was recently fined $100,000 for “failing to perform a comprehensive risk assessment before its server was hacked in May 2015” resulting in what was concluded to be “one of the largest breaches in recent healthcare history!” According to the Resolution Agreement, MIE must assess whether its existing security measures are sufficient to protect its ePHI, and must revise their Corrective Action Plan, Policies and Procedures, and training materials, as needed.
In May of 2019, in an effort to make the HIPAA Privacy Rule as easy to understand as possible, the Office for Civil Rights (OCR) has come up with a list of rules that clearly explain what Business Associates are now “directly liable” for. As OCR Director Roger Severino explains, “We want to make it as easy as possible for regulated entities to understand, and comply with, their obligations under the law.”
The list consists of ten rules that, if failed to follow, can result in penalties and monetary fines.
The OCR has made it very clear that even so much as simply “[failing] to comply with the requirements of the Security Rule” can result in immediate penalties as well.
To this end, one of the most important rules also includes information about Business Associate Agreements and their need for proof of Satisfactory Assurance when the Covered Entity requests this of them.
Satisfactory Assurance is crucial because it ensures the Business Associate is HIPAA Compliant and therefore, must also be in the form of a contract. Because it is so often overlooked, the fact
sheet points out that there would be penalties associated with “Failure to enter into business associate agreements.”
Are you ready when asked by your clients to provide your statement of Satisfactory Assurances?
Checking off your Business Associate requirements, including those listed in the OCR’s fact sheet, is very easy with EZClaim’s trusted HIPAA Compliance Experts, Live Compliance.
First, it is most important that all Business Associates and Vendors have proof of Satisfactory Assurance at least annually, as well as Business Associate Agreement outlining their roles, functions and notification requirements.
Second, Business Associates and Vendors must complete an accurate and thorough Security Risk Assessment. A Security Risk Assessment will target vulnerabilities related to what is potentially exposing Protected Health Information. Failing to do so could also result in a penalty under ‘willful neglect’. This category alone is $50,000 per violation! These fines are huge, but the reputational damage to your billing company and the covered entity is expensive and difficult to overcome. (Live Compliance has a 100% audit pass rate!)
Lastly, employees should be HIPAA trained with relevant course material to their role and your organization. Your workforce is your first line of defense. Completely built into your portal, Live Compliance training is custom, online, and role-based. Training is delivered and monitored within the Live Compliance portal, anytime and from anywhere.
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