GETTING PAID

All-time Practices in Claims Processing

These strategies will help you minimize claims delays and denials and revive your practice's revenues.

Fam Pract Manag. 2003 Jul-Aug;10(vii):xix-22.

Not all of the factors that influence claims payment are within your control, only you tin have steps to lessen at least some of the frustration and unnecessary expense associated with claims delays and denials. The American Association of Wellness Plans, the Healthcare Financial Management Association and the Specialty Society Insurance Coalition recently convened a committee representing health plans, physicians and hospitals to examine bug with claims processing and identify best practices. The strategies described in this commodity are based on data developed by that commission, which includes the American Academy of Family unit Physicians, American College of Obstetricians and Gynecologists, American Academy of Dermatology, Bethesda Healthcare System, Piedmont Hospital, Grouping Health Inc. and Health Alliance Plan.

Your comeback efforts should begin with a careful review of your practice'due south current claims processing systems. Enlist your billing staff (or billing service) to provide y'all with some basic data about your practice'southward claims processing performance. Y'all'll need the following information:

  • The percentage of claims submitted within the last 30 days that were delayed,

  • The percentage of claims submitted inside the final xxx days that were denied on the first submission,

  • The reasons near often given by payers for the delays and denials.

With the assistance of your office managing director, utilise these data along with the best practices provided below to guide your improvement efforts.

Claims submitted to the incorrect payer

If a high percentage of your denied claims are denied because they were submitted to the wrong payer, take the following steps:

  • For new patients, collect information about insurance coverage when they book their first engagement to allow you ample time to procedure it. Ask patients to provide the following information about their spouse and dependents as well as themselves: Social Security number, nascency date and group/policy numbers for each of their insurance providers, including Medicare and Medicaid.

  • Go far a policy to re-create patients' insurance cards at their beginning visit to your role. If the patient has secondary coverage, re-create the carte for that policy as well.

  • Upon each patient'south arrival at your office, review the insurance information you have on file and enquire whether it'south electric current. If the patient makes changes, copy the patient's insurance card again. Go on authentic records of all insurance information (current and previous) for use in claims follow-up, appeals, disputes or coordination-of-benefits issues.

Claims denied due to ineligibility

To reduce the number of claims denied due to ineligibility, confirm eligibility for every patient visit – prior to the visit, if possible. Have your staff notation when eligibility was confirmed and whether information technology was achieved by talking with a payer representative, by using the payer's automatic phone system or online.

Claims denied or delayed due to coordination-of-benefits issues

If your claims are being denied or delayed due to coordination-of-benefits problems, follow these steps:

  • Inquire all patients whether they have secondary or other insurance coverage. Gathering this information and using it when billing the insurance carriers can reduce the number of claims that are delayed pending coordination of benefits.

  • Verify whether each payer listed in the patient's file is the primary or secondary carrier. This can be accomplished when checking eligibility if you practice so via "live" telephone contact. In some instances, if the payer is secondary, the person you talk with may be able to tell you which payer is primary. Hither's a rule of thumb for dependent children covered under more than than one policy: The payer whose subscriber has the before birthday in the calendar twelvemonth will be the master.

  • When submitting a claim to the secondary payer, send a copy of the Caption of Benefits from the primary payer. If you don't, the claim will probably exist denied or delayed awaiting coordination of benefits.

Denied or delayed Medicare claims

To reduce the number of denied or delayed Medicare claims in your office, attempt these tips:

  • Ask new patients age 65 or older (or electric current patients who've turned 65 since their terminal visit) to show you a copy of their Medicare and other insurance cards, and update your records as needed. Remember it is possible for a patient to have just Medicare Office A or Office B or to exist ineligible for Medicare despite being 65 or older. It is besides important to find out whether Medicare-eligible patients have group health insurance. Federal laws determine when Medicare is the chief or secondary payer.

  • If Medicare is the primary payer, check to meet if Medicare automatically "crosses over," or sends claims to, the secondary or other payer. Many health plans pay Medicare for this service. If the patient'southward claim is crossed over and you submit another merits directly to the secondary payer, the latter claim will exist denied as a duplicate. The Explanation of Medicare Benefits should bespeak when a merits has been crossed over for consideration by the secondary payer.

A TOOL FOR FILING CORRECTED CLAIMS

The committee upon whose recommendations this article is based as well developed a ane-page tool that tin help brand the process of filing corrected claims more efficient. The form can be downloaded below and modified to meet your practice's needs.

Download as MS Word document

Download in PDF format

Claims denied as duplicates

If your practice is seeing a substantial number of claims beingness denied every bit duplicates, the post-obit steps tin can help improve your billing procedure:

  • Establish a minimum rebilling cycle of at least xxx days to allow fourth dimension for the original merits to move through the payer's bike. Resubmitting a claim in less time uses unnecessary resources and is likely to result in the claim existence denied as a duplicate.

  • Reconcile claims denials and claims payments at to the lowest degree every 10 days, working through any electronic mistake and rejection reports in the process. This volition help you to avoid common mistakes such as rebilling a denied merits or billing the patient's portion to the insurance carrier.

  • Don't automatically rebill all outstanding claims. When a claim requires follow-upwardly, your first step should exist to contact the payer (past phone or online) for additional information.

Appeals or corrected claims denied as duplicates

To reduce the number of appeals or corrected claims being denied every bit duplicates, follow these steps:

  • Be aware of the special requirements that each of your payers may have for submitting appeals or corrections. For instance, some require that appeals exist submitted on a specific form and not include a copy of the original claim.

  • Unless the program directs yous otherwise, do not simply stamp a claim equally "Second Request" or "Appeal." Such claims volition by and large be treated as new claims and denied as duplicates.

  • Exist sure that the appeal or correction is submitted to the right address. Many payers request that appeals be submitted to an address or post-part box that is unlike from the one used for original claims.

Claims denied due to missing or inaccurate information

If missing or inaccurate information is causing your claims to be denied, enact the post-obit procedure:

  • Double-check every merits for completeness and accuracy prior to sending it to the payer. Mutual billing errors include providing incorrect or incomplete patient information (e.g., member number, policy number, full proper name of subscriber) and incorrect or incomplete service information (east.m., date of service, diagnosis codes, CPT codes and modifiers).

The lesser line

By implementing these strategies, you'll be able to shore up your accounts receivable and optimize your claims processing organization. If your practice is similar near family practices today, you can't beget not to.

To see the total commodity, log in or purchase access.

Leigh Ann Backer is the managing editor of Family unit Practice Management.

Ship comments to fpmedit@aafp.org.

Copyright © 2003 by the American University of Family Physicians.
This content is owned past the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in whatever medium, whether now known or after invented, except every bit authorized in writing by the AAFP. Contact fpmserv@aafp.org for copyright questions and/or permission requests.

Most RECENT Outcome

FPM E-Newsletter

Sign up to receive FPM'southward free, weekly e-newsletter, "Quick Tips & Insights."

Sign Upwards Now