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Partial denials cause the average medical office to lose up to 11% of their revenue. Rejection management is difficult due to the complexity of the reasons for rejection, the variety of payers and the volume of claims. Systematic denial management requires measurement, early claim validation, extensive monitoring, and custom follow-up of the opposition process.
In a high-volume clinic, the only practical way to manage rejections is to use computer technology and follow a four-step process:
- Prevent application submission errors. This can be achieved with an integrated claims validation process including payer-specific tests. Such tests (“pre-submission scrubbing”) compare each claim to the Correct Coding Initiative (CCI) regulations, carefully review modifiers used to distinguish between procedures for the same claim, and compare the calculated amount to the allowable amount according to previous experience or contracts to be avoided undercharge.
- Identify underpayments. Identifying underpayments includes comparing the payment to the allowable amount, identifying zero-paid items, and evaluating the timeliness of the payment. The results of this phase should be displayed in a comprehensive underpayment report sorted by payer, provider, claim identification and the amount of underpayment.
- denials of appeal. Appeal management includes prioritization of appeals, preparation of arguments and documentation, follow-up and escalation. Note that CCI sets bundling standards, but the number of standard interpretations grows with the number of payers. Therefore, CCI provides a reasonable basis for an appeal, and each appeal must be accompanied by its own justification, including medical records. Rejection procedures are typically managed using a custom process tracking system such as TrackLogix.
- Measure rejection rates. “You can’t manage what you can’t measure.” By measuring rejection rates and monitoring payment trends, you can see if your process requires changes.
The risk of rejection is not the same for all claims. Depending on the complexity of the claim, temporary restrictions and the characteristics of the payer, there is a significantly higher risk of rejection for certain classes of claims:
- claims complexity
- modifiers
- Multiple Line Items
- Temporary Restrictions
- patient restriction, e.g. B. Claim Submission During Global Periods
- Payer restrictions, e.g. B. Time of claim submission near the beginning of the fiscal year
- procedure restriction, e.g. B. Experimental Services
- Payer Peculiarities
- Bundled Services
- Disputed medical necessity
First, for complex claims, most payers pay the full amount for an individual item but only a percentage of the remaining items. This payment approach creates two possibilities for underpayment:
- Ordering paid items
- Payment percentage of the remaining items
Next, temporary restrictions often cause payment failures due to incorrect application of restrictions. For example, claims submitted during the global period for services unrelated to the global period are often denied. Similar errors can occur at the beginning of the financial year due to misapplication of deductible rules or outdated fee schedules.
Finally, payers often differ in their interpretation of the Correct Coding Initiative (CCI) bundling rules or the coverage of certain services. Developing sensitivity to such peculiarities is key to making full and timely payments.
Powerful Vericle-like technology helps manage denial requests nationwide and stays current until the issue is fully resolved. Each time an accounting problem is solved, the newfound knowledge is coded for recycling. Sharing billing expertise in a central billing knowledge base speeds future problem solving.
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