Receiving accurate insurance reimbursement for delivered services is always been a challenge for healthcare providers. Practice owners spend most of their time and energy on doing administrative tasks of medical billing to receive sufficient insurance reimbursements to cover overhead expenses and provide quality care. But often they make this task even harder by doing sloppy coding and billing which leads to delayed or incorrect reimbursements from insurance carriers. Providers can follow some practice management guidelines to improve coding and billing accuracy. It will help reduce denials and rejections, ultimately helping to enhance practice collections. These guidelines will help receive timely and accurate reimbursements and avoid the chances of external payer coding or billing audits.
Practice Management Guidelines to Improve Practice Collections
Front Office Issues Leading to Claim Denials
Most practices only focus on submitting claims quickly but no one pays attention to payment posting. Practice owners must generate reports and find out how many claims are submitted and how many are actually paid. Then focus on claims that are denied, or rejected and payment status is mentioned as pending. Basic practice management guidelines would be identifying the most common reasons for claim denials and finding ways to eliminate them. The most common front office-related denial reasons are as follows:
- No patient eligibility check is conducted (no updated insurance coverage report available)
- Absence of prior authorization/precertification for planned services
- Patients’ insurance coverage is expired
- Patients’ coordination of benefits (COB) is missing
- Clinical notes are not concise, detailed, or specific
- Diagnosis lacking specificity
Your front office is where the revenue cycle begins. Your front desk staff must have an insurance coverage report for every patient visit and must be qualified enough to understand the insurance coverage report. Practices also make the following mistakes while making clinical notes leading to claim denials:
- The date of service doesn’t meet frequency limits
- Time spent with the patient for time-based services is not documented
- The note is not signed
- The billing provider’s and service provider’s names don’t match
- The note doesn’t support the CPT codes reported for it
Back Office Issues Leading to Claim Denials
Your back office handles medical coding, communication with insurance carriers, and other activities. The most common issues back offices frequently deal with include the following:
- CPT codes are inconsistent with the place of service
- The patient has reached the benefit maximum for the time period
- Submitting duplicate claims
- Procedure/modification combinations are incompatible
- Referral(s) are not listed on the claim
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