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 ]

Medical Billing Technology Series

Medical Billing Technology Series

Medical billing technology is always changing, and usually much quicker than one expects. While your current processes may be working for you, there just may be something better available to reduce staff time and increase your revenues. The thing is, technology has made huge strides in the medical billing industry in recent years, offering a number of ways to send and receive data faster, while still protecting sensitive patient information.

So, over the next several posts, we will explore different features technology can offer to increase your efficiency as well as your bottom line. We will consider how your Electronic Medical Record (EMR) can communicate with your Practice Management (billing) software, the key features to look for in your Practice Management software, and how it can communicate with other programs, such as Clearinghouses and statement vendors.

 

This Medical Billing Technology Series will include:

    • Validation vs. Scrubbing
    • Rejection vs. Denial
    • Integrating With an EMR
    • Integrating With a Clearinghouse
    • Basics of ANSI/EDI Reports
    • Patient Collection Policy/Credit Card Processing
    • Using Templates
    • Is Integrated Eligibility Worth It?
    • Statement Options
    • Selecting a Practice Management System (Ease of Use/Access; Training; and Support)

 

Now, not every office will benefit from the same “bells and whistles,” and there are so many options out there. It can be overwhelming.  Chances are though, your office could benefit from considering some updates, and some may not even cost you at all!

EZClaim suggests that you take a fresh look at the workflows and processes that you have in place today, and start thinking about the tasks that are wasting time or that are causing delays in collecting payments (from both patients and insurance). These insights just may help you create a positive change to your workflow and your revenues!

 

So, if you need some help getting started, consider working with a consultant. One of EZClaim’s partners, RCM Insight, offers an annual fee schedule review, and during the month of February 2021, they will be offering four practices a FREE fee schedule review. So, visit their CONTACT US page for your chance to win! [ Note: RCM Insight uses EZClaim’s medical billing software for their billing services, so it could be a ‘win-win’ if you are—or will be—using EZClaim’s medical billing solution ].

 


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: Stephanie Cremeans with RCM Insight ]

Collecting Payments from Patients. Find Out How.

Collecting Payments from Patients. Find Out How.

The most important thing a medical practice can do for their financial health is collecting payments from patients. So, because patients are not usually savvy when it comes to the nuts and bolts of their contract, they become frustrated when you send them a bill and, beginning on January 1st, your office staff get inundated with the question, “Why do I have a balance?”

“Approximately 68% of patients with bills of $500 or less did not pay off the full balance during 2016—up from 53% in 2015 and 49% in 2014.” Source: Patients May be the New Payers, But Two in Three Do Not Pay Their Hospital Bills in Full, TransUnion Healthcare, June 26, 2017

So, let’s make sure your office is equipped and able for collecting payments from patients for the services you rendered, rather than them becoming a part of this scary statistic.

Let’s begin with the basics: Make sure that your staff understands these key terms, and is comfortable explaining them to your patients.

Deductible: The deductible is the amount the patient has to pay for covered services before the insurance plan pays. Some insurance plans will apply an office visit to the deductible, others will not. Family plans typically have an individual and family deductible.

Copay & Coinsurance: These are both the portion the patient will be responsible for after their deductible has been met. Copays are a set, flat fee. Coinsurance is a set percentage that the patient will pay.

Maximum Out-of-Pocket: This is the limit of what a patient will pay for covered services within a plan year. Again, on family plans, there may be an individual max and family max.

Now, keep in mind that your staff will not know the details of your patients’ plans, nor should they be expected to! In the ever-changing world of health insurance, patients need to become better consumers. So, just being able to explain these key terms and why they create a patient balance will help them become better insurance plan shoppers!

Use your tools. Look into using Integrated Eligibility (available through your billing software and your clearinghouse). This will allow your staff to check remaining deductible balances, copay, and coinsurance amounts with the click of a button. These results allow practices to confidently collect at the time of service rather than spending time and money on sending statements and working to collect after the visit.

In addition to that, create a plan and stick to it. Use this time to review the efficiency of your patient collections plan. Are you using an outdated plan or policy? Have you considered offering payment plans to patients with an HSA card kept on file? Make sure that your employees understand how important patient collections are to the practice, educate them on the plan, and support them when they hold patients accountable to the patient collections policy.

 

For more information on how EZClaim can help you with this journey, schedule time with our sales team. Or, if you ready to get started right now, then download your FREE 30-day demo today!

[ Written by Stephanie Cremeans of EZClaim ]

‘All-in-One’ or ‘Specialized’ Medical Billing Software? Which is Best?

‘All-in-One’ or ‘Specialized’ Medical Billing Software? Which is Best?

Which is the BEST kind of Medical Billing Software? “All-in-One” or “Specialized”?

When considering WHICH medical billing solution they should use, practices wonder which is best, an “all-in-one” solution or specialized software. Well, the following are a few important pros and cons to consider when making a choice between these solutions.

ALL-IN-ONE:
An “all-in-one” system tries to provide a single, comprehensive solution that offers functionality for the major areas of the practice—Practice Management (PM), Electronic Medical/Health Records (EMR/EHR), and Revenue Cycle Management (RCM)—accessed from one central point. It has features like clinical notes, patient information, and history, diagnosis and treatments, scheduling, appointment reminders, reports, patient educational resources, as well as a medical billing section.

PROS:
• Most of what a practice need is included in the system
• There is no need to be concerned with multiple integrations or vendors

CONS:
• Tends to have a higher ‘entry’ cost
• Usually designed for the “middle-of-the-road,” therefore sometimes doesn’t properly address specific needs of a practice
• Sometimes, the practice is left paying for additional customizations to fit their particular needs

SPECIALIZED SOFTWARE:
Specialized medical billing software, on the other hand, is particularly programmed to maintain billing details of tests, procedures, examinations, diagnoses, and treatments conducted on patients.   However, many specialized software providers extend their scope to include features like practice management, scheduling, and other administrative and clinical functions (that are generally a part of EHR software systems) by partnering with other specialty software companies—creating a “best-in-class” solution.

PROS:
• Integrating multiple “best-in-class” software packages—each taking a much more focused approach—creates an offering with much more in-depth capabilities
• Usually are more ‘nimble’ in responding to industry and regulatory changes
• More ’scalable’ in supporting the growth of a practice

CONS:
• Most of the time the practice has to deal with multiple vendors

 

CONCLUSION:
Where “all-in-one” solutions offer a wide breadth of capabilities across the business, they usually also lack focus, depth, and sophistication. “All-in-one” solutions are usually only efficient in one area, with the other areas tend to be ‘compromised’ and not fully developed. Then, when it comes to flexibility, they tend to be slow to adapt to changing practice needs.

Specialized software, however, typically offer a more efficient experience, with each ‘component’ streamlined and designed with a specific purpose in mind. Their focus on limiting the software scope makes them flexible and easy to use.

EZClaim—a leading software package in medical billing and practice management—has made it easier for the medical practice to have the benefit of a “all-inclusive” solution. They have created the best of both worlds by taking on the responsibility of integrating the “best-of-breed” into a harmonized “best-of-class” offering that allows the practice to pick and choose for their specific needs. The seamless integration of partner products and services ensures the practice does not have to give up robustness and flexibility for a simplified “all-in-one” solution, and it further enhances the practice’s workflow.

As a specific example, one of EZClaim’s partners is TriZetto Provider Solutions (TPS), a provider that seamlessly blends claims processing with revenue management and analytics software, so the practice can get paid faster, and more accurately.

Today, the practice can get the benefit of all the power and ease of use of EZClaim’s medical billing software and all the access and security that is needed when dealing with personal records by using  TPS—which includes patient access, claims and denials management, patient financials, and advisory services.

The powerful integration between EZClaim and TPS efficiently adds functionality to the practice. Now the practice can gain deeper insight into the claim lifecycle, and take the proper steps to improve the overall health of the practice. The right ‘integrated’ solution makes all the difference!

So, if your practice needs more confident billing, after payments, and more informed decisions, but the power of EZClaim and TPS to work for your practice with the integrated suite of revenue cycle solutions.

In addition to TPS, EZClaim has tightly integrated a variety of of ‘components’ to be able to offer an “all-inclusive” best-in-class solution for a medical practice’s needs: Electronic Health Records (EHR), Clearinghouse, statement and payment services, HIPPA compliance, claims scrubbing, appointment reminders, and inventory management. It has partnered with a variety of providers like QuickEMR, BestNotes, and PracticeFusion  [ Click here for an entire list of EZClaim’s partners ].

It is important to note that an “all-in-one” solution does not usually include the Clearinghouse portion that TPS offers. The powerful integration between EZClaim, TPS, and EZClaim’s EMR partners, efficiently adds functionality to ANY practice!

If you are considering the best course of action to meet your practice’s needs, consider using EZClaim by downloading a FREE TRIAL or contact one of their product specialists today to explore all the options for how to best solve your practice’s operational challenges, and grow your business.

For details and features about EZClaim’s medical billing software, visit their website.

3 Keys to Starting Your Medical Billing Practice

3 Keys to Starting Your Medical Billing Practice

Whether you are a person new to medical billing or someone who’s been in the business for years, launching a new medical billing practice can be hard. Understanding the market, connecting with new clients, and knowing how to master your processes are challenges that you often learn as you go. Despite these challenges, it is rewarding to be out on your own growing a new company. Before you jump, let us help you understand some essential keys that you can research upfront and prepare yourself to get one step closer to being successful.

1. ONE BILLING PLATFORM VERSUS MULTIPLE PLATFORMS: First and foremost you must make a conscious decision to either focus on being an expert on an individual medical billing platform, like EZClaim or tackling multiple platforms.  There are pros and cons of both: being an expert can make you extremely efficient in your use of the software’s billing and, scheduling features, however, it can also limit your client base to only one set of software users. Whereas having a basic understanding of multiple platforms can allow you a larger base of medical offices while limiting your ability to truly understand how best to serve each individual client’s needs.  

Pro tip: Start and master one trusted billing program, and grow your options as your billing business grows.

2. GET CLEAR ON THE CLEARINGHOUSE: A new billing company owner does not want to be held to just one clearinghouse as options are key here. Having the ability to work with any or many would be an essential piece to your billing services, however, you still want to know the best clearinghouses in the business. Understanding which clearinghouses provide the best products and services and being able to recommend those services to your client upfront will make your life easier and their business run smoother. For this very reason, EZClaim has built its software around partnerships and integrations with the best clearinghouses to make working with the one you need easy.

3. COMPLY OR DIE (HIPAA Compliance): The third key to any start-up is first understanding the importance of HIPAA Compliance. Medical billing firms literally can come crashing down with any missteps, mistakes, or misunderstandings of this essential piece of the puzzle. It goes without saying that if you are going to choose a billing software be sure that they have partnerships built around making sure you are protected. You are also responsible to make sure the data is protected so your customer and their patient’s data is safe.

HIPAA Hint: Check out Live Compliance for further details on the topic. 

There are many options available out there for your new medical billing practice, and we recommend doing your research. Within that research, you will find that EZClaim ranks very high in performance and comes in at a great price.

To learn about EZClaim go to our about page, sign up for a demo, and/or download a trial for free today!