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Healthcare policies and rules are continuously changing, and it’s important to stay on top of what all insurance carriers are doing and how their changes impact your practice’s revenue cycle. This, as well as managing your accounts receivable (A/R), is the best way to ensure your cash flow does not bottleneck and cause damage to your practice’s livelihood.

Coding Consultant, Hospitalist, Medical Billing, Mobile Charge Capture

10 Steps Will Help You Prevent Medical Claim Denials And Maximize Cash Flow

Key facts to remember:

$262b - Total healthcare claims denials in a year
3-5% - Average claim denial rate (of total revenue)
90% - Denials preventable
67% - Denials can be overturned with appeal
75% - Denials and rejections due to ineligibility
35% - Providers appeal denials
75 minutes - Time spent per denial
20% - Remittance sent on paper

Top 5 reasons for claim denials

According to the American Medical Association National Health Insurer Report Card, these are the top 5 reasons for claims denials:

Missing information
Duplicate claims
Service already settled
Service ineligible according to a healthcare plan
Missed deadline

Following 10 steps will help you prevent denials and maximize cash flow.

Step 1: Verify Patient Demographics and Eligibility

This should be done at the front desk during the first contact with the patient. Hold front-end staff accountable for front-end denials but allow them to work with claims denial avoidance or medical billing teams to understand patient demographic errors and services not covered by the patient’s plan. Some tips when verifying insurance are:

Complete verification prior to the patient being seen.
Collect copayments at initial visits.
Make a copy of the patient’s ID, front and back.
Have all forms signed and dated, including the financial policy annually
Collect copay, deductible, and co-insurance, as applicable.
Require the start and end dates for insurance carriers.

Reading and analyzing insurance cards and identifying differences in key payers’ cards when billing is important for entering the correct info into your PM system. Things you should be looking for on the front and back of the cards are what the plan type is, the Payer ID, when the policy starts and ends, symbols, and whether there is a health savings account (HSA) linked to the plan. Be sure all information is correct when registering the patient. The name on the insurance card should match the name on the registration forms exactly, and you should get the patient’s complete address; P.O. boxes should only be used for mailing purposes. Also confirm the phone number, insurance information, and employer are correct.

Step 2: Check for Deficiencies in Provider Documentation

Deficiencies in provider documentation can cause all sorts of problems. Insufficient documentation can cause claims to be down-coded or denied, cause retraction of previous payment, or flag practices for prepayment review. Common documentation deficiencies that cause billing hang-ups are:

No provider’s signature
Missing or improper CPT®/HCPCS Level II modifiers
Missing clinical/medical necessity for lab orders
Undocumented procedures
Missing details from the patient encounter
Cloned documentation

Step 3: Make Sure Charge Entry Is Correct on the Claim Form

It’s important to know where the charge entry goes on the claim form. To know if something is correct or incorrect, you need to know where the information came from. ’s eight tips for charge entry review:

Make sure all billable charges are entered.
Review for lost revenue (administration codes, supplies, etc.).
Determine if code modifications are necessary for reimbursement such as applying modifiers, multiple procedure rules etc.
Make sure the charges are entered in accordance with payer policy.

Step 4: Scrub A Claim

Before you click the claim submission button, prepare the claim and determine if any modifications are needed. Be sure you are pointing the diagnosis correctly to justify the procedure that was done.

Step 5: Evaluate Your Payment Posting Process

When posting payments, you need to know your gross collection rates (GCR) and net collection rates (NCR). Pay attention to whether your carriers are paying your contracted fee. To evaluate the payment posting process:

Reconcile remits. Make sure payments correctly match in your contracted rate.
Audit contractual obligation (CO) write-offs. There are times when a CO is not a true write-off.
Send timely statements. Move patient balances over right away.
Generate reports through the PM system for write-offs and adjustments to make sure they are correct.
Handle and resolve denials.

Step 6: Work on A/R

The most important aspect of managing A/R is follow-up and decide whether your A/R should be worked on weekly, monthly, quarterly, or yearly. Your goal should be to keep insurance A/R aging under 90 days. To keep patient A/R from aging, offer automated alerts and several payment options, such as:

Payment portals that are tied to your PM system
Credit cards and debit cards
Checks and cash
Merchant accounts through your website
Money transfer apps set up for business (e.g., Venmo, PayPal, Zelle)

Step 7: Analyze the Causes of Billing Denials and Delays

Know the difference between a rejected claim and a denied claim. A rejected claim means you did not have the necessary information to determine coverage, such as a billing error. A denied claim does not meet the coverage criteria. Approximately 93 percent of rejections are due to data entry and are preventable, while 70 percent of denials can be overturned. Causes of rejections, delays, and denials include:

Step 8: Analyze data and Leverage Technology

Finally, effectively monitor your organization’s A/R by running reports based on date of service (DOS) on. Use the following reports as staff learning tools, set up goals, and make staff accountable to fix errors hurting your practice’s revenue cycle:

Practice analysis
Insurance analysis
Charge and payment analysis
Patient aging
Secondary claims status
Denials
Adjustments

It’s easy to lose track of denial claims and allow them to pile up. This makes tracking even more difficult and results in lost revenue and profitability. By investing in software that automates this process, you’re able to streamline. This simplifies tracking claims, including resubmitted requests, and helps stop revenue loss.

Step 9: Communicate and Educate

One of the most important aspects of your improvement program is to apply lessons learned. This is best achieved by establishing a robust training program. Place or promote super users within departments to help support new and existing staff with demographics and insurance questions. Super users should be individuals that have strong skills with departmental workflows, system knowledge, have a good rapport with staff, be very knowledgeable with demographics and insurance issues and have wide revenue cycle knowledge. Along with performing their job responsibilities, super users assist management with the daily staff questions and can help manage the denials process.

Step 10: Audit aggressively

Conduct monthly staff audits for accuracy with front-end and billing teams. Eliminate repeated occurrences with claim errors for all avenues of the revenue cycle or the life of a charge. Findings from staff audits can identify errors such as staff not applying a modifier appropriately to a service, not obtaining a required authorization or not entering it correctly or continuing to resubmit claims with denials that have not been resolved. Conduct chart audits routinely for quality standards for data and documentation. Reporting on monthly audits results is a proactive strategy for helping to ensure cleaner claims and reducing payor denials.

Further resource:

About DocCharge

DocCharge: Be productive again! Practice analytics, mobile charge capture, HIPAA compliant messaging, and tools for billers.
DocCharge is a mobile physician productivity platform enabling physicians and clinicians to save time by efficiently capture patient billings, communicate with back office and maximize revenue by avoiding lost charges using real-time analytics on a mobile device. Designed by a physician for fellow physicians, residents/fellows, and mid-level providers, DocCharge maximizes one’s productivity. Practice Administrators and outsourced billing companies find the application very intuitive, thus improving practice efficiency and revenue.
DocCharge is transforming healthcare data into useful and actionable insights, thereby allowing partner subscribers to focus their resources on the core business of providing high quality patient care. For more information, visit www.DocCharge.com, email: contact@DocCharge.com.

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