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Why Did My Medical Billing Claim Get Denied?

Why Did My Medical Billing Claim Get Denied?

If a medical billing program has “scrubbing,” why did my medical billing claim still get denied? It is a common question that we are going to answer today.

First, let’s get a better understanding of the words we are talking about.  In the medical billing world, validation and scrubbing tend to be used interchangeably.  While they are similar – they are not actually the same. Understanding what you have and what you need will help you submit ‘clean’ claims.

According to Technopedia, data validation checks for the integrity and validity of data and ensures the data complies with the requirements. So, what requirements? Often people assume that this means payer requirements, but that is typically not standard. Validation rules are built into your practice management software and can be used for several points.  Following are some common rules you may find in your program:

  • Ensure NPI‘s and Tax IDs are the appropriate lengths
  • Ensure patients date of birth is entered
  • Ensure that a procedure code and place of service are present on each claim

 

While these scenarios are standard across the industry, there may be other situations that a validation rule can help. Some programs will allow you to create custom rules for your practice. A customized validation rule will allow you to create a rule for a payer requirement.  For instance, you could create a rule to prevent the following:

  • Do you have a code that always requires a modifier, but only for a specific payer?
  • Work with pediatrics and always need the ‘relationship to insured’ to read something other than self
  • How about insurance ID numbers that are a specific alpha-numeric combo, like 3 letters followed by 9 digits?

 

Keep in mind, if you are creating validation rules the program will make sure that the criteria are met based on the rule entered into your software. When creating custom rules, it is important to note that this will not verify payer billing guidelines. You will need to obtain information directly from your payer to create a rule that coincides with their policies.

Once any validation errors have been addressed your claims will go to the clearinghouse you are working with. Most clearinghouses offer claim scrubbing for an additional fee.  Technopedia defines data scrubbing as the procedure of identifying and then modifying or removing incomplete, incorrect, inaccurately formatted, or repeated data.

 

Claim scrubbing is available in several ways. It may be used within your practice management system, your clearinghouse, or even a third-party vendor. Claim scrubbing services can vary greatly in what they are looking for.

Once the claim has left your practice management system it will likely go through at least 2 scrubbing programs—one with the clearinghouse and one with your payer, prior to accepting the claim for processing. When claims are found to have an error, these results are sent back through a Claim Status Report (ANSI 277 file or a human-readable text file). This report will include information about why the claim cannot be processed. This report will also indicate whether it is the clearinghouse or the payer that is rejecting the claim. If you have further questions about the rejection, you will need to contact the entity that has rejected it.

 

Checking the Claim Status Reports on a regular basis will help you correct the errors and resubmit in a timely manner. In addition, the information you have gathered from the rejections can be used to update internal processes or create customized validation rules to prevent future rejections for the same error–saving you time and money!

RCM Insight is a medical billing company that uses EZClaim’s medical billing software. For any details that have to do with claims validation and “scrubbing,” contact RCM Insight directly.


ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.

[ Contribution by Stephanie Cremean’s with RCM Insights ]

4 Tips To Reducing Claim Denials in 2021

4 Tips To Reducing Claim Denials in 2021

Reducing claim denials has long been a challenge for providers. In the worst case, denied claims end up as unexpected—and sometimes unaffordable—bills for patients. The challenge only seems to be growingA recent survey conducted by the American Hospital Association (AHA) found that 89% of respondents had seen a noticeable increase in denials over the past three years, with 51% describing the increase as “significant.”

Minimizing loss will be top of mind for providers as the COVID-19 pandemic continues to put a strain on their resources, and minimizing or preventing denials will need to be a core part of that strategy. With that in mind, we’re offering four tips to help guide revenue cycle strategies for better denial reduction in 2021.

 

1. Analyze and Assess

In order to achieve and maintain a healthier denial rate, it’s vital to have a good handle on the factors creating problems in the first place. Keep the following in mind as you start to structure your analysis:

  • Review key performance indicators: Take a look at which metrics are being used to benchmark success or failure and see if it’s time for a refresh
  • Evaluate workflows: It’s important to have a clear understanding of how your team operates, and that you can detail workflows as step-by-step processes
  • Assess tools: Inventory the software you’re using and discuss with your team how it helps or hinders them
  • Staff efficiency: Consider the number of team members and resources involved in each step of the denial management process

It’s also important to talk to staff. Your team can offer invaluable insight on what is and isn’t working to help you develop a more comprehensive understanding of the shape and scope of the systemic issues contributing to your denial rate.

2. Reduce Errors Upfront

Eligibility, registration, and authorization errors remain the greatest cause of denials and write-offs, so a good first step is to focus on being proactive instead of reactive. Often, it’s easy to get into a routine where errors are only addressed after they occur. But incorporating tech to verify coverage and benefit accuracy in advance can lead to higher efficiency and much less manual labor spent to correct those issues later on.

Similarly, a recent AHA report found a failure to obtain prior authorization to be one of the most common reasons for a claim to be denied by a commercial health plan. In another recent survey, the American Medical Association found that 86% of providers surveyed were struggling with a high administrative burden created by prior authorizations.

Recent innovations have made the process simpler than ever. The right prior authorization solution can automate the process and make it simpler, smarter, and much less labor-intensive, reducing manual input errors and preventing denials.

3. Cut Down on Manual Labor

Claim denials are often the result of staff trying to keep track of a seemingly overwhelming number of rules and regulations while juggling various systems and filing requirements. When your staff is overburdened, it’s that much easier for them to make simple errors or miss deadlines.

There are numerous tools available for teams who are either struggling with paper-based processes or databases without automation. With an AI-powered solution, you can streamline a number of time-consuming tasks while simultaneously automatically ensuring you’re identifying missing data or claim errors that can be corrected before they’re submitted.

It’s also a good idea to review any potential new tools with your team. Their insight will help you properly determine which solutions will actually improve their workflows, and which could prove an expensive time sink.

4. Use Stronger Reporting Tools

Accurate and in-depth reporting should be core to your strategy. Effective reporting tools let you quantify and assess the issues that influence your denial rate, allowing you to easily spot persistent workflow errors or other systemic problems that can create extra work or strain resources.

New tools powered by AI and machine learning offer more robust reporting options than ever, with advanced analytics and visualization capabilities that make it easy to explore complex data sets or identify trends. Mountains of information can now be easily managed and measured, giving you access to operational insights that will help you better understand problem areas and identify opportunities for improvement.

 

The Wrap-up

With the right tools, a solid strategy, and expert guidance, you can take a proactive approach to reducing claim denials. Our automated tools make it easy for your team to streamline their workflows while reducing errors and administrative costs. With Hubble, our AI and RPA platform, you can unlock the insights you need to reduce your denial rate and increase cash flow.

Waystar, a partner of EZClaim, also offers a number of front-end solutions to help you take a more proactive approach to your denial rate.  Click here to learn more about how Waystar can help you with reducing claim denials and claim management. For more information about Waystar’s platform, visit their website, or give them a call at 844.492.9782.

To find out more about EZClaim’s medical billing software, visit their website, e-mail their support team, or call them at 877.650-0904.

[ Contribution: Waystar ]

Check, Check and Check!

Check, Check and Check!

Claim Status Inquiry – EZClaim and Trizetto Provider Solutions

 

Tired of manually checking the status of your claims? Learn how using Claim Status Inquiry allows you to instantly access the up-to-date status of your claims, sent directly and in real-time from hundreds of payers – ending the need to manually check the status of your claims.

EZClaim and TriZetto Provider Solutions can help you identify and fix rejected claims and reduce data entry and phone calls to payers to check on claim status. Stay on top of the claims you submit every day and save your staff hours of work every week!

•   Access up-to-date status of your claims from hundreds of payers
•   Take action to fix and resubmit your rejected claims
•   Learn from your most common rejections to reduce the chance of reoccurrence

Click Here To Get Started

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