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Stop Denials Before They Start

Practices focusing on long-term and post-acute care (LTPAC) constantly battle with claim rejections and denials. These claim denials increase billing expenses and cause harm to revenue cycle management. Submitting clean claims with a high first-pass approval rate is crucial for prompt reimbursements. Preventing rejected claims also saves employee time and effort required for resubmissions and appeals. A quality electronic health record (EHR) system helps you comply with regulations and increase profitability, allowing clinicians to focus on patient care.

Electronic Medical Records (EMRs) are electronic versions of the paper charts used to enter patients' medical data. An EMR system contains the medical and treatment history of the patients in your practice. EHRs go beyond EMRs; they are meant to be shared with other healthcare providers, laboratories, and the patients themselves. A good EHR system will also integrate seamlessly with your organization's practice management software and billing and coding software, speeding the workflow and reducing errors.

A study of health insurers by the American Medical Association found that 29% of claims were denied by major payers. About half of these claims are never resubmitted, leading to lost revenue. Resubmitting claims is also costly; your organization spends approximately $25 for reworking each denied claim. Fortunately, technology is now available that reduces claim denial and allows your organization to focus on improving the quality of patient care.

Claim Denial — Common Reasons

Missing information: A claim must be complete in all respects to achieve quick reimbursement. Your organization providing LTPAC must ensure that all data is included in the claim in the proper format:

  • Place of service (POS)
  • Current Procedural Terminology (CPT) codes for evaluation and management (E&M)
  • At least one ICD10 diagnosis
  • Details of Time Spent for CPT codes as required

Inappropriate billing: Submitting a bill for a service not allowed for your POS will certainly cause a denial. Similarly, certain diagnoses are not valid as a primary diagnosis for billing.

Patient data: Claims are often rejected for missing or incorrect patient IDs. Other essential information is the chief complaint and history of present illness (CC/HPI), past, family, and social history, and psychological risk.

Delay: Each payer specifies a time frame during which claims must be submitted. Failure to meet the deadline results in losses, as those payments must be written off.

Denial Reduction Strategies

Lost revenue affects everyone in your organization, and it's no surprise that almost every member has a role to play in denial reduction plans. Some essential components of your strategy should include the following:

  • Schedulers must collect accurate demographic and insurance data.
  • Registration should confirm that all patient identification data is correct.
  • Nurses should enter all this data into the EHR system.
  • Clinicians must ensure that their documentation covers all services provided to the patient.
  • Support staff must check for coverage for services provided and obtain pre-authorization as needed.
  • Coding and billing staff should extract accurate diagnostic codes, procedure codes, modifiers, and other data that affect billing.
  • The billing office must submit claims on time.

Every claim should be checked to ensure all required data is included. It is vital to perform these checks before sending the claim to the payer. This avoids payments being delayed or lost due to denied claims.

Using Technology to Improve Revenue Cycle Management

Healthcare claims are complex, and errors are frequent when entering data. Payers often reject or deny these flawed claims, delaying and reducing your revenues. Your organization can reduce these costly mistakes by adopting EHR software with automated claim filing. Implementing automation is among the best practices for reducing claims denials.

Automation not only cuts out errors but also speeds up the claims submission process. Data discrepancies that delay claim settlements are also greatly reduced. The automation eliminates some of the work for your billing department, saving costs. You can reap these benefits by adopting a comprehensive EHR system. An ideal EHR verifies claims before submission to payers. Such verification should include:

  • Place of Service (POS)
  • CPT code for E&M
  • At least one ICD10 (diagnosis) code for billable claims
  • Checking bills with CPT codes that require Time Spent to ensure clinicians have entered the minimum time threshold or more
  • Checking Start and Stop Time as needed to ensure the required data has been provided
  • Holding back bills with invalid diagnoses to have the primary diagnosis corrected
  • Requiring certain sections of data be entered before bills can be submitted (Social History, Psychological Risk, and CC/HPI)
  • Verifying that CPT codes billed are valid for the Place of Service

Chartpath is an Austin, TX, based solution provider for physician practices. Our easy-to-use systems handle documentation, billing, and revenue cycle management (RCM) seamlessly, freeing you up to focus on caring for your patients. Chartpath offers the benefits of a custom-built EHR system designed for long-term and post-acute care (LTPAC) practices. Our 24/7 support helps clinicians maximize efficiency and profitability.

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