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6 Denial Prevention Strategies to Improve Your Medical Billing and A/R

By Donyelle Fenton

September 27, 2022

Quick, efficient collection of accounts receivables is essential to the sustainability and growth of any healthcare organization – regardless of size. With medical services often provided before payment is collected, proper protocols need to be in place to ensure strong cash flow. Incorrect patient information, inefficient clinical documentation, improper claim follow-up procedures, and poorly trained A/R staff result in slow claim processing.

Here are six practices you can implement right now to help improve your cash flow:

Patient Registration and Information

Obtain and maintain correct patient data. Incorrect patient/guarantor demographics or insurance details result in delayed payments and lost revenue. Responsible parties may not receive invoices and payors may deny claims for ‘Subscriber/member not found’ or ‘Information submitted does not match records,’ which adds unnecessary volume to aging claim records. Left unaddressed, claims are denied and these data gaps require more staff time to correct and resubmit.

Best Practice 1: Ensure staff are verifying and updating patient information every time patients come in.

When appropriate and accurate patient data is collected, the benefit verification process is smoother.

Best Practice 2: Educate your team about questions they should ask, show them how to identify common patient employment status and age errors, and let staff know if unique circumstances should be handled differently.

It is very important to capture thorough patient data on the front end.

Clinical Documentation and Coding

Since claim charges are determined by the patient’s medical record documentation, documentation integrity and coding capture protocols ensure that claims are processed and paid on time.

Best Practice 3: Ensure your providers understand the importance and impact of poor documentation.

Improper documentation can result in missed or incorrect charges, which translates to delayed or lost revenue. It can also trigger audits.

Clinical Documentation Integrity (CDI) and Computer-Assisted Coding (CAC) software help identify and eliminate inadequate clinical documentation and charge capture errors. When using a CDI and/or CAC software, not only will the clinical records be more detailed and accurate, but coders will also have all the information they need to code accounts. In addition to CDI and CAC, internal auditing software also helps identify missed revenue opportunities or red flags that could trigger audits.

Best Practice 4: Embrace the technology available to identify and improve documentation and coding.

The cost to obtain software and train your staff is small compared to the revenue improvements you will see.

A/R Follow-up

Follow-up is key to steady revenue collections. Often, many services are provided in advance of payment with the assumption that the insurance or financially responsible party will pay the balance once the insurance has processed the claim. It is the responsibility of the A/R team to manage all open and outstanding unpaid claims that are pending payment.

Best Practice 5: Timely follow-up of aging claims helps to identify and prevent error trends in other revenue cycle areas - preventing revenue loss due to late filing.

Having a team of A/R specialists with a deep understanding of payor guidelines and knowing how to communicate effectively with the insurance claim representatives is important. Often, insurance claim centers process claims incorrectly for various reasons. Many times, they have incorrect information on provider participation and programming edits that erroneously deny or underpay claims.

More commonly, when contacting a claims department regarding an underpaid or denied claim, A/R specialists are instructed to submit an appeal and, in some cases, an appeal is necessary. However, appealing claims can delay payment longer as the average appeal takes approximately 60 days.

Your A/R specialist should clearly identify why the claim was denied/underpaid and what steps to take to reprocess it.

Best Practice 6: Your A/R specialists should know how to read and understand remit and denial codes as they are listed on EOBs/EOPs, and they should know how to review clinical documentation for appropriate claim corrections and resubmissions.

Moving Forward

While there is no one size fits all approach to collecting more A/R, it is important to know what options are available and to have the right people or technology in place. Adequate staff training, clear and consistent communication, and technology are great ways to collect A/R.

Donyelle Fenton

Author

Associate Director of Customer Service,
AGS Health

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