How Not to Lose a Claim Denial

As you know, a denied claim can hurt a physician practice significantly. Losing a claim wreaks havoc on the practice by draining needed revenues. The good news is that there are ways you can avoid future denials.

Record the Reason for Every Claim Denial

The goal should be for your practice to have its claims accepted on the first submission. But this requires taking steps much earlier in the revenue cycle.

To begin the process, identify and record the exact reason for every claim denial. This can be done quickly and easily by using a denial management module that's built into the overall practice management system. A variety of reasons will come up: The payer may insist that the stated diagnosis doesn't support the medical necessity of the services, or there may be missing paperwork in the documentation for the claim. The claim may be denied if the patient isn't a covered beneficiary of the payer to whom the claim was submitted.

The various reasons that emerge should guide your practice to take two types of actions: 1) Make immediate efforts to correct the errors and reverse the denial, and 2) modify your practice processes to prevent the errors from occurring in the future.

Correct and Resubmit

There are several possible responses to a claim denial. For instance, once the root cause of the denial is established, try to correct and resubmit the claim. Make sure you locate any missing paperwork and then add it to the claim. You can change inaccurate codes to the right ones, or determine the patient's correct insurer and submit the claim to it.

If the practice can't fix the reason for the denial, or the payer refuses to accept the correction, it may make sense to drop the matter and write off the charge. A write-off is necessary if the practice can't locate the documentation to support the claimed service or if it turns out that the service was really part of a bundle that already has been paid separately and never should have been claimed in the first place. Nonetheless, this should be the last resort to a denial.

You can also appeal the claim. In the event that your practice makes what it believes to be appropriate corrections, but the payer still rejects them, the last option is to appeal the decision. You'll need to contact the payer to learn its reasoning on the matter. Then, you must prepare persuasive arguments in support of the claim. As appropriate, gather additional relevant documentation, or obtain more expansive statements of medical necessity from your clinicians. Finally, file the appeal and follow up with the payer every two weeks until the matter is resolved.

Going Forward

Your practice's goal should be to avoid claim denials, so you'll need to make systemic changes for the future. For instance, with the change from ICD-9 to ICD-10 billing codes, which was implemented on Oct. 1, 2015, it's likely you'll encounter problems with incomplete documentation or improper coding that may require retraining staff and clinicians. The people may be fine, but the processes they perform may need to be re-engineered. In that case, your focus should be on getting all the right patient information before or during registration, capturing and entering the correct charge codes in a timely manner and, last, correcting preadjudication edits returned by the claims clearinghouse on a daily basis.

By following the above objectives, your practice will be well on its way to clean claims. It's also important to understand the causes of claim denials. This starts with reporting denials at the claim level and on a line-item basis, and then projecting trends over time.

The Bottom Line

Face it, your practice wasn't created to lose money. So be sure to include a chat with your health care advisor or coding professional. He or she can help you keep on the right track.

Please contact Deirdre Hartmann, CPA or Harlene Stevens, CPA on (973) 328-1825 for additional information or to discuss further.