Follow sound procedures to avert claims denials
Follow sound procedures to avert claims denials
Do it right the first time, the experts say
An ounce of prevention is worth a pound of cure — and that goes double when it comes to avoiding claims denials from managed care organizations.
In many cases, it’s the technicalities that result in outright denial of claims by managed care companies, says Tammy Tipton, chief executive officer of Appeal Solutions, a Lewisville, TX, health care consulting firm specializing in insurance claims.
The best way to avoid having your claims denied by insurance companies is to cross your T’s and dot your I’s when you submit the claim.
"If you do it right on the front end, you’ll have fewer problems on the back end," asserts John Nosek, MPA, CMPE, executive director of Greensboro (NC) Orthopedic Center.
The first step in avoiding denied claims is negotiating a contract you can live with, says Sue Binder, RN, CCM, principal of Integrated Healthcare Consultants in Caldwell, NJ. Her firm contracts with physician practices to manage patient care.
Binder suggests having someone knowledgeable about claims carefully read any contracts with managed care companies before you sign them. This way, the contract won’t put any undue burden on your staff that could result in denial of claims because of technicalities. (For more information on contracting with insurers, see related article on p. 66.)
Make sure you hire people who are skilled at claims processing to collect your accounts receivables, Binder suggests. "The clinical side must have a business side, and successful practices are those that have people who are skilled in that area," she adds.
Either the physicians in your practice have to spend a lot of time on the business end of the practice, or you must hire competent staff and delegate the responsibility to them, she points out.
Improperly coded procedures are the first thing to slow down payment, Nosek says. He suggests establishing ongoing training for your claims staff to make sure they are aware of code changes.
For instance, Sarasota (FL) Memorial Hospital’s physician-hospital organization, a 440-member PHO, has payer representatives come in and explain to the staff how they expect their claims to be submitted, says Gary Hickerson, director of operations.
Here are some other tips on how to avoid claims denials:
• Be very aware of the billing requirements for each specific contract. Your billing staff should fully understand the contracts and its stipulations.
• Make sure you comply with the time limit for submitting claims. Some contracts specify that claims are invalid if they aren’t submitted within 90 days of treatment.
• Make sure your staff know the proper people to contact at the insurance firm.
• Establish an auditing process to make sure your billing staff follow the procedures, and hold staff accountable, Nosek says.
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