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 ]

Modernizing Medical Billing Payments

Modernizing Medical Billing Payments

How to Modernize Your Medical Billing Payments Now

It is now very important to modernize medical billing payments capabilities since upwards of 80% of medical services that don’t get paid by insurance, never get paid!

Are you tired of providing medical services and not getting paid? Have you billed patients for their medical visit or co-pay just to find out that the bill showed up in collections? Are you looking for a better way to use modern technology to increase the number of medical claims being paid on time?  If you own a medical practice or work in the medical billing industry, then chances are you have answered each question with a hearty Yes!

 

Last month, medical billing industry leaders came together to discuss how medical practices can streamline their payment systems and integrate credit card processing into their billing system. [ Participants: Dan Loch (VP of Sales & Marketing, EZClaim), Tony Peterson (VP of Business Development, BillFlash), and Michael Jones (Payment Services Analyst, FullSteam) all joined host Susan Martinez (Sales Consultant, EZClaim) ].

[ Click Here to LISTEN to the Exclusive Podcast ]

Medical Billing Payments Podcast

[ Click Here to VIEW the Exclusive Video ]

KEYS That Came Out of the Discussion:

• CHANGING SYSTEMS AND PROCESSES: The practices that are winning in the payment collections game, and seeing the highest percentage of claims paid, are the offices that have updated their systems from the old school and traditional forms of payment collection to the modern, state-of-the-art systems with payment integration. Plain and simple, this means first educating the patient from the moment they walk in the door and streamlining your payments into one medical billing system to prevent human error. [ Click here to LEARN MORE ].

• STREAMLINING CREDIT CARD PROCESSING: Practices often have jumped headlong into credit card processing by using simple systems with variable fees like Square or Stripe. The problem with that is two-fold: First, understanding processing fees, and secondly, avoiding the errors that occur in the steps of processing those purchases over to the billing record. However, now EZClaim’s medical billing software has an integrated payment featurewhich streamlines the billing and simplifies the fees. [ Click here to LEARN MORE ].

 

These are only a few of the very informational topics that were discussed during this podcast. If you are interested in learning how your practice can put these systems in place, increase patient payments, and simplify your billing process in your office, then click here to listen to the podcast and prepare to learn some new,  up-to-the-minute ‘insights’ on modern medical billing systems. 


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.

5 Things Medical Practices Need to Get Right in 2021

5 Things Medical Practices Need to Get Right in 2021

There are five primary medical practice fundamentals that, if focused on, will ensure your practice is working toward goals that will make the biggest difference. Practices are pulled in many directions each day, and it can be difficult to know what to prioritize, so the following are some recommendations.

1) Define Patient Engagement Goals
Perhaps one of the most overused terms in today’s medical field is “patient engagement.” Much like the drawer filled with important yet miscellaneous items, if you can’t actually define it, you probably aren’t going to do something with it.

In 2021, it is imperative to define your office’s patient engagement goals in order to determine whether they are being met, and more importantly, if the value you’ve placed on engagement is benefitting your bottom line. This could include engaging via a more personal checkout process that explains how billing and payment will be done and asking patients if there are certain times of the year they wish to be notified for annual wellness checks.

2) Ask For Online Reviews
Reviews remain one of the highest drivers of new customer acquisition. As a local business, you can create a Google Business account online that provides your address, phone number, and link to your website. Included is the ability to add reviews as well as phrases and keywords about your business within the Google Business dashboard, and it’s all free!

To encourage your patients to leave reviews, create cards with step-by-step instructions for posting online reviews via Google. Be picky. Make sure you ask your best patients to participate, who will be honored that you asked. Don’t forget to monitor to see how your business listing looks to potential new patients.

3) Offer Friendly Medical Bills
Of course, we’re not suggesting you add flowers or poignant sayings. Rather, explain a statement to your patients at checkout or within their financial package; this helps the process flow more naturally. BillFlash patient statements have five different messaging rows you can customize for communication. Plus, you can also send electronic patient statements through text and email.

In 2021, communication with patients—even on billing statements—should be natural, friendly, and simple. Getting paid is a segment of the medical practice workflow and should be as easy and frictionless as possible.

4) Ask About Payment Preferences
People are driven by routine and behavior. In today’s world, when paying for an item, the buyer is offered numerous options including cash, debit and credit, no-interest, pay-over-time plans, payment apps, or even Near Field Communication (NFC) like Apple and Google Pay. Granted, the last two have had very low adoption rates, but keeping an eye on payment trends costs little more than time and may add something unexpected to your bottom line.

In 2021, identifying the preferred patient payment options could be the difference between getting paid quickly and not getting paid at all. Don’t overlook the enormous value people place on how they give and take money.

5) Use RCM Services
An RCM vendor helps you get the most out of your practice revenue. They help you collect more from difficult balances, empower patients to pay in full, and improve your claims processing—without adding extra work for your office staff. Working with the right RCM services provider ensures you are paid more for the work you do. They also help identify reasons for claims denials, which have a positive impact on your practice revenue, as well.

 

For more information about automated patient statements and patient payment options, contact EZClaimNexTrust BillFlashGetPaid@BillFlash.com, or call BillFlash at 435.940.9123 (Option 3). For more details about EZClaim’s medical billing software, visit their website, e-mail their support team, or call them at 877.650.0904.

Medical Billing Service Has Used EZClaim for Over 15 Years

Medical Billing Service Has Used EZClaim for Over 15 Years

Deborah Rieser founded Spectrum Medical Billing Services in Anchorage, Alaska 15 years ago to make extra money to help with paying the family’s bills. Today, she owns a thriving medical billing service with a team of “twelve lovely ladies”—as she likes to refer to them—that services clients nationwide. Rieser originally selected EZClaim’s medical billing software platform—because of its pricing structure—to use for her medical billing service.

Over the years, since her original purchase, she has upgraded to each new EZClaim version, which adding new features and efficiencies.  Recently, she has made the transition to EZClaim Cloud, and continues to use it exclusively today.

With team members nationwide, Rieser prides herself on training her billers on properly classifying billing for medical offices so that there are minimal insurance denials. She is very particular about this since one of the reasons Deborah began billing was the insurance qualification struggles she had for her daughter with Autism. So, accurate billing is ‘personal’.

Recently, we found time to interview Rieser about her start in the industry, the ups and downs of being a business owner, and what hard-fought expertise she has gained that might help others considering to start their own medical billing service. 

EZCLAIM: When did you get into the medical billing industry and why?
RIESER: “I always had an entrepreneurial spirit, and I had an orchid business out of our house. Then my daughter, who was born with Autism, started working with an Occupational Therapist (OT),  and they came to me to help with billing. I thought about it, and after a few weeks, I took it on. That was back in 2005.

“At that time, my daughter had over 75 volunteers and therapists in the community work with her from age three to age five, and had 50-60 hours a week of therapy. Today, she is a sophomore in  university, has a boyfriend, is driving her car, and is thriving. From all of that, I have always felt the need to give back to the community for all their help. So, I used my business to take on other Pediatric, Occupational Therapy, Physical Therapy, and Speech Therapy clients, as well as, using my experience to help patients take care of their billing needs and get their bills paid by insurance.”

EZCLAIM: What are you passionate about when it comes to billing?
RIESER: “For me, the biggest thing that I am passionate about is seeing my clients [medical offices] getting paid from insurance claims. I also enjoy helping patients get properly classified during medical visits, so claims are accepted. I have learned a lot from the mistakes and errors that have led to denied claims. From my experience, I can help medical practices observe their approach to patients’ needs so that services qualify when billing insurance companies. Being able to offer that to my clients is very satisfying.”

EZCLAIM: What are some of the challenges you have had to overcome?
RIESER: “Originally, we grew word-of-mouth. I didn’t even want a website at first, but now I do have one. Going from one client to 65 is challenging because as your clients grow, your staff grows. Recently, I lost a client. You then have to decide what you’re going to do with your staff. The hardest part is that, for a business owner, your business consistently goes up and down. That fluctuation can be stressful. For me, I deal with that by going outdoors. My husband and I will go for a walk in nature and that will help relieve my stress.”

EZCLAIM: What advice would you offer others in the billing industry that have similar experiences?
RIESER: “If you’re starting your own business, make sure it’s one you love. Know that there will always be highs and lows. Also, be sure to price yourself accordingly. You can’t go too high or people will look elsewhere.

“I do want to step back and highlight that some of my billing practices only do 2-3 claims a week, and that’s why I love EZClaim. The price of the software. When I was growing, I was working on EZClaim “Advance,” which is being retired. So, when I started looking around at other software providers, they were billed on a ‘per provider cost.’ Fortunately, EZClaim “Cloud” billed based on the number of concurrent users, which worked for me.” 

EZCLAIM: How has your relationship with AMBA (American Medical Billing Association) benefitted you?
RIESER: “I just joined last year in 2019, thanks to EZClaim and Dan Loch’s referral. I love that group. I joined their Facebook group because they have very useful information for us billers. I recommended that my team members join as well. They are good at supporting US-based companies and put the focus on supporting the group.”

EZCLAIM: What would you tell people who are wondering if EZClaim Cloud is right for them?
RIESER: “The transition to EZClaim Cloud was easy. I was worried about the providers and the tax ID’s, but it all was very smooth. I would add that customer support was very helpful. As daunting as moving things over felt, it was very smooth. I attribute that to the planning and support.”

EZCLAIM: What would you say would be a strength of someone who is good at billing and coding?
RIESER: “It is important to be a very good communicator, professional, out-going, and enjoy what you do. One must be able to communicate with providers over denials, success, celebrations, and always keep talking with the staff and the providers. Also, always try to put yourself in the patients’ shoes by offering patience and compassion. Lots of times patients don’t understand their benefits and why they are denied. So, try to explain in layman’s terms. They understand better and appreciate that. It ends up being a good connection with the patient, and benefits you as the biller, too.”

EZCLAIM: Final thoughts?
RIESER: “I am grateful to EZClaim for their services.  As a business owner, you have to monitor expenses and things can add up fast. So, I am thankful for EZClaim Cloud and its pricing structure. That has helped Spectrum Medical Billing Services to grow and thrive.”

[ The above answers were paraphrased as closely as possible to the original answers given by Deborah Rieser on November 25, 2020 ].


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 a representative today at 877.650.0904.

Life Cycle of a Medical Bill (Revenue Cycle 101)

Life Cycle of a Medical Bill (Revenue Cycle 101)

Life Cycle of a Medical BillThere are five ‘phases’ in the life cycle of a medical bill: Pre-appointment; Point of care; Claim submission; Insurance payment or denial; and Patient payment. This post will overview each of these phases, and could even be considered to be a “101-level” course on Revenue Cycle Management.

With high deductible health plans on the rise, the recent explosion of telehealth appointments due to COVID-19, and many other factors in play, it’s more important than ever for everyone to understand the life cycle of a medical bill, and how the process works. The healthcare revenue cycle is relevant not only to those who work in healthcare, but to the patient, too.

The revenue cycle is the series of processes around healthcare payments—from the time a patient makes an appointment to the time a provider is paid—and everything in between. One way to think of it is in terms of the life cycle of a medical bill. Although there are many ways this process can play out, this post will lay out a common example below:

1. Pre-appointment
For most general care, the first stage of the revenue cycle begins when a patient contacts a provider to set up their appointment. Generally this is when relevant patient information will begin to be collected for the eventual bill, referred to on the financial side of healthcare as a claim.

At this point a provider will determine whether the appointment and procedure will need prior authorization from an insurance company (referred to as the payer). Also, the electronic health record (EHR) used to help generate the claim is created, and will begin to accumulate further detail as the provider sends an eligibility inquiry to check into the patient’s insurance coverage.

2. Point of care
The next step in the process begins when the patient arrives for their appointment. This could include when a patient arrives for an initial consultation, an outpatient procedure, or for a follow-up exam. This could also include a Telehealth appointment.

At any of these events, the provider may charge an up-front cost. One example of this is a co-pay, which is the set amount patients pay after their deductible (if they are insured), however, there are other kinds of payments that fall into this category, too.

3. Claim submission
After the point of care, the provider completes and submits a claim with the appropriate codes to the payer. In order to accomplish that, billing staff must collect all necessary documentation and attach it to the claim. After submitting the claim to the payer, the provider’s team will monitor whether a claim has been been accepted, rejected, or denied.

[ Note: Medical coding refers to the clerical process of translating steps in the patient experience with reference numbers. The codes are normally based on medical documentation, such as a doctor’s notes or laboratory results. These explain to a payer how a patient was diagnosed and treated, and why. This information helps the payer decide how much of an encounter is covered under any given insurance plan, and therefore how much the payer will pay. ]

4. Insurance payment or denial
Once the payer receives the claim, they ensure it contains complete information and agrees with provider and patient records. If there is an error, the claim will be rejected outright and the provider will have to submit a corrected claim.

The payer then begins the review process, referred to as adjudication. Payers evaluate claims for accurate coding and documentation, medical necessity, appropriate authorization, and more. Through this process, the payer decides their financial obligation. Any factor could cause the payer to deny the claim.

If the claim is approved, the payer submits payment to the provider with information explaining details of their decision. If the claim is denied, the provider will need to determine if the original needs to be corrected, or if it makes more sense to appeal the payer’s decision.

Following adjudication, the payer will send an explanation of benefits (EOB) to the patient. This EOB will provide a breakdown of how the patient’s coverage matched up to the charges attached to their care. It is not a billing statement, but it does show what the provider charged the payer, what portion insurance covers, and how much the patient is responsible for.

5. Patient payment
The next phase occurs when the provider sends the patient a statement for their portion of financial responsibility. This stage occurs once the provider and payer have agreed on the details of the claim, what has been paid, and what is still owed.

The last step occurs when a patient pays the balance that they owe the provider for their care. Depending on the amount, the patient may be able pay it all at once, or they might need to work with the provider on a payment plan.

 

The above example represents one way the lie cycle of a medical bill can play out. Some of the ‘phases’ are often repeated. Because of the complexity of healthcare payments and the parties involved, there is not always a ‘straight line’ from patient care to complete payment. That’s why we call it the revenue cycle, and there are companies that provide systems for its management.

One of EZClaim’s partners, Waystar, aims to simplify and unify healthcare payments. Their technology automates many parts of the billing process laid out above, so it takes less time and energy for providers and their teams, and is more transparent for patients (Click here to learn more about how Waystar automates manual tasks and streamlines workflows.) When the revenue cycle is operating at its most efficient, providers can focus their resources on improving patient care—and that’s a better way forward for everyone!

For more information of how Waystar works together with EZClaim, click here.

[ Article and image provided by Waystar ]

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ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support, and can help improve medical billing revenues. To learn more, visit their website, e-mail them at sales@ezclaim.com, or call a representative today at 877.650.0904.