Claim Denial! Definitely not a river in Egypt!

Revenue Cycle ManagementHaving worked with Revenue Cycle professionals over the last few years, gives me a finer appreciation of the work that provider organizations have to do to get paid. We’ve all received those bills we thought that the insurance company would have taken care of and wondered why are we receiving this? Why can’t I get through to the company that has sent me this? Did I really get disconnected after holding on this phone for 15 minutes? Frustration can certainly mount. I know it does for my family when trying to figure out next steps. According to an article from Healthcare Finance that I recently read, the top 5 medical claim denials that are the most common are:

1) Duplicate claims – When hospital administration resubmit claims when they have not heard back from the payer and end up restarting the clock for that claim and end up mostly with a denial due to re-submission

2) Lack of information on the claim – When a claim is processed but due to human errors, information such as a date of birth or the spelling of a name is incorrect, the claim gets denied.:

3) Expiration of Eligibility – When both the patient and the provider organization are unaware that the insurance eligibility of a patient has expired with that organization. This is a common mistake that can be avoided if the provider does an eligibility verification before and during when the patient comes in for their appointment.

4) Claim not covered by the payer – Providers can easily avoid this by leveraging the ability to use real time verification capabilities.

5) Time limit expiration –  Basically, the provider did not send the claim in on time as apparently many times, smaller providers don’t focus on smaller claims, but want to make sure larger claims are paid leaving a lot of smaller claim dollars on the table that eventually add up.

All in all, payer organizations also leverage the system to their benefit as any organization would. It is up to the patient to understand their eligibility options and the provider to recoup the money that they are owed. There are many opportunities for revenue cycle improvements that are more often than not, simple to deduce, but more difficult to achieve.

 

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