Written by Amanda Campbell
As a medical billing and collections specialist for the last 11 years, I find the most common denials and/or rejections are related to registration errors.
Denials vs. Rejections
I would like to point out to begin with, there is a critical difference between a rejection and a denial: A rejection is a front end scrub of the claim, usually before the claim enters the adjudication system. You will typically receive a report back through your clearing house advising of inaccurate data that needs to be corrected and resubmitted (Please note, from an auditing stand point any changes made to a claim in a clearinghouse should also be made in the practice management system). A denial comes from the payer once a claim has been processed that needs to be corrected and refiled if applicable.
Now that we understand the difference between a rejection and a denial let’s think through some ways to avoid both.
It is the reality, be it a physician’s office or in a hospital setting, that we are all moving at a fast pace and sometimes miss a “key” during the data entry process – no big deal right? Not the case! Did you know something as minor as a misspelled name or even a date of birth can cause a claim to deny with a payer?
When I worked in registration, I encouraged a check list to use to monitor and ensure daily activities were done correctly and in the proper order. Even now on the other side as a Consultant, I always urge a check and balance system – for example the check list. A reality of the healthcare industry is turn-over. They are going to happen and again, with the fast paced world we work in, training is typically a minimum of what needs to be done to get a claim out the door and move on. So with a checklist that bullet points checking of names, checking of date of birth, accurateness of policy and group numbers, obtaining a new copy of insurance cards, etc. can tremendously turn around the amount of registration related denials and/or rejections that your practice receives.
Your Clearinghouse Fits In Too
With all this said, another check and balance should be your clearinghouse. Ensure that your clearinghouse is set-up in a way to receive real time data back from payers. As a provider you may say “Well we have a billing company that reviews all that information for us.” In that case, strongly urge the billing company to track and document that data in order to provide feedback.
As a Consulting agency ourselves, with clients where we handle the billing functions from beginning to end, we understand that not everyone is aware of what is truly involved in getting claims paid cleanly and quickly, especially when you do not physically see the rejections and denials.
Troubleshooting the Issues
There are many things we do for our clients and it all starts with identifying an issue. As I tell everyone in our industry when trying to identify an issue – one rejection or denial is an eye-brow raiser, two of the same rejections or denials should catch your attention and throw a yellow flag, three or more of the same rejection or denial is a red flag that needs to be brought to someone’s attention. In these situations, we will try to figure out what the root cause of the issue is: Is someone adding a hyphen in the Medicare Policy number that our system does not recognize? Does this patient have an HMO? Are policy numbers being transposed? Does this patient not have benefits for this specialty?
These are all things we are going to look into and in turn report back to our client. We report this information in an effort to help teach our front office staff what to look for, the quirks of your practice management system, and which insurance companies require what information.
There are various ways to avoid any registration related issues, in which we at Legacy Consulting could help expand the knowledge and even assist with training!
Tell us more about your rejections and denial woes in the comments.