In a down economy, it’s critical that physicians keep an eye on cash flow … particularly payments from insurers. To ensure your practice’s cash flow keeps flowing, you must win more appeals on claim denials and, better yet, reduce denials by submitting clean claims in the first place.

Common Denials

Some of the most notable denials that practices must deal with relate to the type of provider (NP, PA, etc.) that the patient is permitted to see under their plan, global charges billed when only the professional or technical component should have been billed, claims not submitted within the timely filing guidelines, and patients ineligible for service.

Most denials are caused by administrative errors such as inaccurate data entered into the system, authorizations not executed correctly, and so forth. Something as simple as employing a billing manager and a certified coding professional can improve your chances or submitting error-free claims as well as diagnosing denial problems.

Coding, Coding, Coding

If you have a certified coder on the front end, you and your medical staff will be able to immediately interact with the coder to ask questions, clarify the proper diagnosis, and verify the scope of visits allowed as dictated by coding policies. Certified coders have access to online manuals and coding software that can enhance the accuracy of code combinations, modifiers and definitions of what’s a medical necessity.

And a certified coder working on the back end can help your practice capture revenue that might be overlooked. Coders should note discrepancies between procedures documented and supplies ordered but not billed, find missed charges based on the coder’s review of the physician’s documentation in his or her progress notes, and verify that diagnosis codes being billed are appropriate for the service(s) rendered at that time.

By editing on the back end, you’re more likely to save time reworking later, reduce denials and number of days in accounts receivable, and increase revenue.

Knowing How To Appeal

If claims are denied, consider whether you should appeal. Writing and preparing appeals takes time and a lot of research. These are critical items you should include in an appeal:

• An account of the patient’s treatment,
• The connection between the treatment and the patient’s medical history and complaints,
• How the treatment benefited the patient,
• If inpatient, the reasoning behind the length of stay in the hospital, and
• The accountability from other practitioners and medical societies that the type of treatment a patient received is based on the condition.

Finally, ensure that you’re fully aware of all appeal rights and using the proper forms per payor.

Forming a Denial Team

Further, create a “denial team” to collect data regarding denials you’ve received. Then review the data and put a process into place to educate the staff based on a corrective action plan to minimize further denials of the same type.

A primary area of education to focus on is the Advance Beneficiary Notice (ABN). This form allows the provider to bill a patient for services that aren’t covered by the insurance plan. It’s also critical to understand payor guidelines. Designate one person to receive and read all guidelines and guideline changes from payors. He or she needs to be well versed in guidelines for such issues as insurance coverage and eligibility; modifiers usage; and billing for more complex issues.

The investment in training and education will build confidence in those who handle denials. This investment will pay for itself with more fluid cash flow and less time spent working the accounts receivable.

Understanding The Process Is Key

To ensure your practice gets the payments it deserves, minimize the number of claim denials by keeping an eagle eye on coding and claims editing, understanding the appeals process and creating a “denial” team. Your CPA or financial advisor can help you along the way.