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Are You Seeing Claim Rejections? This Could Be Why
By: Stacy Toner
We perform billing services for many Orthotic and Prosthetic companies across the country, in doing so we see many different reasons for claim errors which allows us to identify and track trends. One of the biggest reasons we see, not only in O&P but in healthcare in general, is “incorrect patient demographics”. Ironically, this is also one error that as providers, we have the most control over. So, why is it so common? There are plenty of causes such as lack of training, lack of attention to detail or even general lack of intake procedures. This article will offer some ways to avoid the causes that make up 61% of all claims errors in the healthcare industry (1.).
Let’s start off talking about which patient demographics are necessary to be present and correct for a claim to be accepted for processing.
- Full patient name
- Patient’s date of birth
- Patient address
- Insurance policy number
- Insurance group number
Next, I want to talk about the difference between a claim denial and a claim rejection. A claim denial means that the claim was received into the payer’s claims processing system, assigned a claim number and errors were found during the adjudication process.
A claim rejection means that the claim never actually made it into the payer’s claims processing system and a claim number was never assigned. A rejection gone unnoticed by a biller can be very dangerous because there is no proof that the claim was ever submitted in a timely fashion if the payer never received it for processing.
Looking at the list one may think, “that’s simple enough, what’s the problem with getting that”? Unfortunately, there are many ways the information can be missed, misinterpreted or messed up. But, no need to worry because there are also many ways to avoid the errors that cause denials.
Ways to avoid errors:
1. Have an intake sheet that covers all patient demographics and make sure your admin confirms all information prior to checking the patient in
Having a detailed intake form will get most of the necessary information but there is always the chance of the patient writing something incorrectly or their handwriting being illegible. It is always a good idea to verbally confirm the information on the sheet if any of it is hard to read.
2. Get copies of everything on the patients first visit
The importance of this tip cannot be stressed enough! Getting a copy of the patient’s license will ensure you have the proper spelling of his/her name and the correct date of birth; and copies of insurance cards will ensure you have not only the correct ID but phone numbers, address and payor ID for the patient’s insurance plan.
3. Confirm any information changes at each visit
Patient information changes all the time. Patients move, change insurance plans, get married etc. My primary care physician requires me to review my own information and sign a form indicating no changes have been made at every visit and, that process works for them. Anytime something has changed, they had the updates before billing my claims. Having that small step will save your billing staff a lot of headache and extra work.
Some denials are unavoidable, that is just the nature of medical billing. However, if you can put processes in place to avoid 61% of denials before you even submit the claim then you are just putting yourself ahead of the game. Avoiding these common errors will make your practice more efficient and decrease bottlenecks in your cashflow.
Resources: (1.) Lachney, Kamron. “Medical Billing Denials Are Avoidable: How to Help Prevent the Top 5.” Change Healthcare, 26 Aug. 2016, www.changehealthcare.com/blog/medical-billing-denials-avoidable/.
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