| Frequently,
claims are delayed because of incomplete and inaccurate information
on the claim submission. Not all of the factors that influence
claims payment are within our control, but you can take steps
to lessen at least some of the frustration and unnecessary expense
associated with claim delays and denials. Specific
areas have been noted as being problem issues in the past
with claim submission and new strategies have been developed
to address the concerns.
For
actual improvement in claim submission it is necessary that
you First: Carefully review your practices
current claims processing systems. Enlist your billing staff
to provide you with some basic information:
 The
percentage of claims submitted within the last 30 days that
were delayed.
The
percentage of claims submitted within the last 30 days that
were denied on the first submission
The
most frequent reasons given by payers for delays and denials
In
addition there is “A
Self-Assessment Tool for Providers” that is designed
to assist providers in better understanding the processes
used within their own practice to submit and track claims.
The
use of this data and the new strategies can guide you to improvement
efforts in the following areas.
Claims
submitted to the wrong payer
If
a large percentage were denied due to submission to wrong
payers, attempt the following:
With
new patients, collect all insurance information when they
schedule their first appointment, i.e. SSN, birth date,
group/policy number and ask specifically who holds the policy
for each plan, including Medicare.
Implement
policy to copy all patients’ insurance cards during
first visit.
Claims
denied due to ineligibility
In
line with collecting the proper data prior to the first
appoint, confirm coverage during this time. Have staff document
eligibility passed on automated system or healthcare representative.
Claims
delayed or denied due to coordination-of-benefits
Confirm
any secondary insurance during each visit; patients sometimes
forget they have 2 policies.
If
there are other policies prior to claim submission confirm
which one is primary and secondary. This may require contacting
either insurer; if you are able to speak with a live representative
confirm with them the primary insurer.
For
every submission to the secondary payer, include an Explanation
of Benefits from the primary. If you don’t, the claim
will be denied or delayed pending coordination of benefits.
Medicare
denied or delayed claims
Ask
new patients 65 years or older (as well as current patients
who have or will soon be 65) to supply a copy of their Medicare
card. Specifically ask what type of coverage they have,
there are two Parts A & B.
If
Medicare becomes primary confirm if it has crossed over
with the old payer. This will decrease duplicate claims
being sent to the former private insurer for primary reasons.
Keep in mind they may still have the same payer
but as a secondary or supplemental plan to Medicare.
Denial
of duplicate claims
Establish
a minimum rebilling cycle of at least 30 days (depending
on your states payment laws) to allow time for the original
claim to be processed.
Reconcile
claim denials and payment at least every 10 days, working
through electronic error and rejection reports.
DO
NOT automatically rebill all outstanding claims. If follow-up
is needed, contact the payer first. Duplicate claims can
result in more phone/online time hassle with payers trying
to track down both claims for the same date-of-service.
Appeals
or corrected claims as duplicates
Be
aware of special requirement required by each payer has
for appeals and corrections. Keep a running file with the
“Claim
Correction Form.”
Confirm
address requirement for appeals and corrections. Most of
the time these claims are sent to another address or P.O.
Box.
Denial
of claims for missing or inaccurate information
Create
a review process of all claims prior to submission. Common
error are transcribed numbers in the policy, SSN, DOB, and
coding.
We
are hopeful that improvement efforts with these issues in
mind will reduce the errors associated with claim submission.
The
premises for these strategies were created by the joint committee
of the American Association of Health Plans, the Healthcare
Financial Management Association and the Specialty Society
of Insurance Coalition.
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