Receiving accurate insurance reimbursement for delivered services is always been a challenge for healthcare providers. Practice owners spend most of the 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 in reducing denials and rejections, ultimately helping to improve practice collections. These guidelines will not only help to receive timely and accurate reimbursements but also avoid chances of external payer coding or billing audits. 

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 must find out how many claims are submitted and how many are actually paid. Then focus on claims which 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 patients 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

When such issues occur, it’s the back office’s responsibility to rectify them as quickly as possible, then share the feedback with the source of the errors. You might lose thousands of dollars for an external payer audit due to such back-office mistakes.  Some of the recommendations include the following:

• Conduct internal monitoring and periodic billing and coding audits
• Implement compliance and practice standards by developing written standards and procedures
• Conduct periodic training and education on the standards and procedures for all your staff
• Investigate violations or allegations of violations and disclose any incidents to the appropriate government entity
• Develop open lines of communication such as staff meetings on how to avoid erroneous or fraudulent conduct

You can use the internal audit feedback to learn, protect your practice, and make sure that you’re improving your practice collections and reducing compliance risk.

Medical billing and coding require manpower with the desired skill set and medical specialty-specific billing and coding experience.  Hiring and constantly training, skilled manpower is the right solution to improve practice collections while remaining compliant with payer billing and reimbursement guidelines. In case of a lack of skilled manpower or to reduce high payroll costs, you can outsource your medical billing operations to a medical billing company.  MedicalBillersandCoders (MBC) is such leading revenue cycle company providing complete medical billing services. To know more about our medical billing and coding services, you can contact us at [email protected] / 888-357-3226