We spoke a lot about a wide variety of issues that an RCM team might typically face in our previous article. These issues can be broadly classified into Operational Issues, Financial Issues, Communication Issues and Issues related to Patient Care. It is needless to say that all these issues if not managed well can result in loss of revenue.

There is no standard solution to these issues as each Provider's or each Facilities challenges are also unique. However, there are some common issues across the Healthcare Industry. Working on these issues can result in better financial outcomes. It is also imperative to be proactive than reactive. This has got a lot to do with the work culture within the organization. If you are reactive, you will always end up working on solving the issues but if you are proactive, you could avoid those issues.

Let's now throw some light on some of the most common issues in RCM and how you can avoid getting into difficult situation by being Proactive.

Not attacking the Denials at the Root Cause?

In the RCM industry, denials are persistent. Quite often, the RCM process owners or the billing / AR staff are working like machines to manage the denial volumes. It is just like working next to a conveyor belt dealing with one denial after the other like a robot. What staff is failing to do here is to bring in efficiencies in the process that could avoid these denials or even reduce them considerably. In other words, they are just not being Proactive. Once of the biggest failures here is improper communication between departments and improper communication from the front office with the patients.

By the end of the day, all these mishaps collectively fall on one team to figure out and solve - The AR & Denials Team. This is why they end up spending most of the time in back and forth communication between departments or with the insurance companies.

Below are some of the denials, ways to handle it and identifying root causes to avoid denials:

Claim denied as not medically necessary / Pending for medical notes:

Reactive Approach:

• If a claim is denied as not medically necessary, verify with insurance why they are not medically necessary & check whether they received any appeal / medical notes to substantiate the denial.
• If they do not have the medical notes on file, draft an appeal & pull all the medical records for the DOS for the patient & appeal the claim.

Proactive Approach:

• Ensure that you verify coverage prior to admission.
• Some of the medical necessity denials are caused simply because of registration errors. Try to limit registration errors and ensure to double check.
• Denial in this case can also occur if the documentation is incomplete. The best way to deal with this is to maintain a protocol or a check list to ensure the documentation is complete.

Claim denied for eligibility or Prior-Authorizations:

Reactive Approach:

• If a claim is denied for eligibility of the member verify the members effective & term dates for the policy & check whether the patient has any other plan apart from the existing plan, if yes verify the information & update the same in the system.
• If reps do not have the information check the available websites with the patient’s name, DOB, SSN & verify if the patient has any other policy.
• If no insurance is found call the patient & take the insurance details for the DOS & update in the system and re-bill the claim to the correct insurance / correct member ID.
• If the patient does not have coverage at all with any insurance bill the patient for the charges.
• If a claim is denied for no prior authorization call the insurance & verify the patient’s benefits & check whether that service require prior auth / referral as per the patient’s plan.
• Call the insurance to see if they had authorization for the hospital charge. If so, have authorization tied to our charge and get the claim reprocessed, If not contact the provider’s office & request authorization# if they have.
• Verify the POS to check if authorization is required for that service as ER services does not require a prior - authorization.

Proactive Approach:

• Get the basics right. Make sure you have captured demographics correctly to perform Eligibility Verification prior to patient visit.
• Do not partially verify. Collect as much information as you can. Most of the facilities verify important information and assume that is enough. However they end up getting into situation where more information was required to determine whether the patient is eligible on not.
• Make sure the coverage is verified on all primary and secondary payors.
• Rightly determine the type of plan - PPO, HMO, POS etc...
• Capture coverage start and end dates and timely filing limits.
• Verify if the provider is in-network and if prior authorizations are required.
• Verify the Co-Insurance percentage, Co-Pay and Deductibles if any
• And lastly, check if there are any exclusions or limitations in patient's policy.

In correct eligibility also leads to other denials like Claim Denied for Non-Covered Service. This could be either because the patient might not be eligible or the provider himself might not be eligible to bill or may not be enrolled. Hence it is very important to get this first step right.

Claim Denied for CPT-DX Mismatch:

Reactive Approach:

• If the claim is denied as CPT billed does not match with the Dx billed, check the insurance edits (Clinical bulletin policy) of the carrier & if the denial is correct then forward the claim to coding for review & charge correction & re-bill the corrected claim to the insurance.
• If the claim is denied as non payable without the primary CPT, then check the primary CPT billed & verify whether it’s an Add-on code if it's not then request the rep to send the claim back for reprocessing.

Proactive Approach:

• During the Coding and Charge Entry process, make sure the CPT codes and ICD Codes are appropriately taken
• It is natural for human errors to occur. The only way to solve this problem is to do a thorough audit of the codes before billing them rather than spending more time later

Claim denied for late filing:

Reactive Approach:

• If a claim is denied for late filing, verify with the insurance received date of the claim & the filing limit for par & non par providers.
• Check the billing history & verify when the claim was sent first and check what type of proof they accept as proof of timely filing.
• If the claim was filed with-in the time frame initially pull the ecommerce / clearing house report & appeal the claim with proof of filing limit.

Proactive Approach:

• This has got more to do with proper time management and proper tracking of your billing. Streamline processes in such a way where you do not miss out on billing a claim.
• Put proper tracking and reporting mechanisms in place that will highlight the ones that are nearing timely filing.
• Maintain a job aid of timely filing limits.

Claim denied as Duplicate:

Reactive Approach:

• Charge Duplication – During the charge entry process the same charges can be entered multiple times in error, need to verify in the system whether the charges were entered twice for the same DOS.
• Multiple submissions – Claims can also be denied as duplicates if they are submitted multiple times to the insurance, therefore need to verify with the rep about the status of the original claim.
• Multiple procedures – In a claim we may bill for 2 or more units of the same procedure for the same DOS which might be denied as duplicate, therefore need check the system if those CPT’s were billed with appropriate modifiers.
• Multiple providers – Claims billed for multiple providers from the same group can be denied as duplicates, however we need to verify with the insurance rep the providers name so that it can be billed with an appropriate modifier to differentiate the charge.
• After verifying all the above information take the appropriate action based on the scenario.
• If the denial is incorrect request rep to send the claim back for reprocessing & if the denial is correct forward the same to coding / billing dept to do the appropriate corrections.

Proactive Approach:

• Search for duplicate entries before billing
• Ensure modifiers are not repeated
• Ensure proper tracking mechanism that provides a list of claims submitted and not submitted to avoid duplicate billing or build this feature into the system

These are some of the denials. However there are lot more depending on the situation. Without proper systems, processes and team in place it can get overwhelming for the RCM staff to ensure everything is taken care of well and there are no denials.

At Promantra, we offer customized RCM solutions that focuses on solving problem for each of our client. We understand that no two clients are the same and their issues are not the same as well. And hence we treat every client differently and customize the process to suit the need and focus towards streamlining their process.

In case you have challenges in managing your denials or are receiving too many denials than usual,

Contact Promantra Today.

Chirag Patel
AVP - Corporate Communications
chiragb@promantra.us
Phone: +1-732-414-3678