Denial Process Streamlined

PCG Software chief operating officer RN, CPHQ's Andria Jacobs, said that denying the requirements for doctors can be frustrating. However, if they are left unattended, it will generate a large amount of unpaid income. Her company is located in Las Vegas, Nevada. It gets dedicated to developing healthcare applications that focus on cost control, fraud, and abuse detection.

Jacobs said that payers generally reject about 5% to 15% of physician requests, although other sources believe this ratio may be higher. Although this may be partly because the payer has better editing and screening and full-time auditors to view the claim, she encourages doctors to simplify their accounts receivable process to cover the refusal to pay.

Jacobs stated that when she performed the valuation, she found that many practices failed to follow up on rejected or pending claims.

However, physicians cannot expect to handle bills alone. A dedicated person is needed to control the process. Someone can follow up and ensure that these claims get handled directly to find opportunities for more income.

She said, first of all, the billing staff must bill correctly. Many offices rely on the codes in their EHRs. She said the problem is that not all of the updates for HER are including the needed billing codes yearly.

She has seen where certain codes have gotten deleted in July have never gotten replaced. For several months, this practice has been billing for deleted codes. These specific codes will never get paid.

She suggested that the practice should also review its tools and billing tools to ensure regular updates.

Then, the practice needs to track which claims gotten denied and why. You can do this by looking at any messages used by the remittance or health plan to tell you that there is a problem with your claim.

After clearly explaining why rejecting the claim, the settlement staff must immediately make changes and then resubmit a clean claim.

After that, it is essential to track the payment time of the resubmitted claim, which is usually between 15 and 30 days (sometimes longer) after submission.

She said that in striving for payment on time, a more positive approach needs to get taken as medical treatment needs to be paid on time. There needs to be a positive approach should be taken. Otherwise, they must pay interest fines, and will firmly support these fines because it is crucial to get all the benefits they deserve.

She said that if the payment does not get made on time after resubmitting a clean claim, then someone needs to step in and send the tracker to see where the claim is and what the status is.

If this becomes a persistent problem, it may be time for physicians to reassess their relationship with the payer.

Jacobs said that while dealing with rejections seems to require much extra work. It is financially worthwhile. 50% to 60% of rejected claims have not gotten reprocessed. That may be much unpaid money.

Getting large payments from patients may seem tricky, but Jacobs said that the billing person needs to contact the patient and figure out how to do what is most convenient for the patient to pay. During her tenure, she did things such as providing electronic payment options to sending bills in a colored envelope. She said: "I would rather get $10 a month for the next ten months than write off $100."

She said that all of these steps to improve the recovery process of rejection incidents should not be accidental. That requires a systematic process so that you know what is working and what is working.

Besides, it is essential to train billing personnel and provide them with resources to handle denials, whether it is sending them to coding conferences, training courses, or ensuring they have access to web-based resources.

The whole goal is to protect patients from incorrect billing and to ensure that doctors receive income.