A successful medical billing team requires the capacity and process for following up on claims. According to the Center for Medicare and Medicaid Services, around 30% of claims are denied, never received, or ignored. Failing to follow up on denied claims results in lost revenue for a clinic, and preventative steps are only a part of the solution. A strong billing system needs the billers to stay on top of claims status and know how a denial can be recovered through appeals.

Typically, denied claims are caused by these common issues: incorrect information, lacking coverage by the insurance, coding, authorizations, and medical records requests. Due to the complexity of billing, issues could have happened at any point in the process. The front desk might have written down incorrect patient information, which then reflects on the claim’s accuracy. While it could be a sign medical biller figuring out denied claimthat the office needs to streamline their systems, it also means that the billers need to have a process in place for catching those denied claims.

Without the right management software, a denied claim can go unrecognized and lose its chance for an appeal. Or, in some cases, the claim needs to be resubmitted with medical records, and the biller should be aware of the steps needed for claim acceptance and full reimbursement. Overall, timing is a huge part of the revenue cycle. Payables have a set time frame that they can be submitted and resubmitted—otherwise the insurer will not be liable for the expenses. Additionally, after the claim has been approved and paid, the patient needs time to submit their payment as well.

Once the denied claim is back in the biller’s hands, they need to follow the right procedure. Insurance companies may have different appeal processes, so billers will have to be aware of that and adjust accordingly. Steps may include:

  • A summary of why the claim is being appealed and the medical records documentation that supports it.
  • Collecting relevant documentation, such as authorizations, referrals, operative reports etc. to support the appeal and services rendered.
  • Calling the insurance. Depending on the insurance, you will only need to call them to clarify confusion about a small issue like a code used.

If you still have questions about this process and how it would apply to your clinic, give us a call to ask your questions. Outsource Receivables Inc. serves specialty clinics across the nation and has offices in Minneapolis, Chicago, and Boston.

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