The Smart Medical Practice

Top 6 Ways Medical Billers Can Avoid Claim Rejections and Denials


Medical billers have a tough job. They are tasked with keeping healthcare providers on solid financial ground through billing and payment and satisfying patients with timely, reliable processing and payment of their health insurance claims. This task requires expert knowledge of the ever-changing regulations, accurate coding and the ability to navigate the many different claims processes of health insurance companies.

Faced with these challenges, it’s hard enough getting claims processed, but then you receive the news a claim has either been rejected by a clearing house or denied by an insurance company. It takes time and effort to track down the causes of each denial, make the necessary changes and resubmit the claim. The last thing a medical biller wants is to get caught in a seemingly endless cycle of delays and confusion.

According to Gina Wysor, owner and operator of Alabama-basedAdvanced Reimbursement Solutions, medical billers can avoid unnecessary delays and denials by paying close attention to the details.

  1. Submit a clean claim without errors or entries difficult to read.Double check the originating documents, such as the superbill or patient insurance card before submitting the claim.avoid medical claim denials
  2. Get updated patient information each time a patient visits. Require they fill in your form and check them for completion prior to treatment.
  3. Clearing houses don’t always catch coding errors, so double check claims when entering. Up-to-date medical billing software can help with this process, but make sure your software is compliant with current regulations.
  4. Don’t assume patients understand their Explanation of Benefits (EOB); they almost never do. Help them to understand why their claims have been denied or unpaid.
  5. Routinely run reports from your practice management software to look for trends – percentages of claims denied and common reasons. Also look for insurance companies that seem to be causing most of the denials.
  6. Process claims reliably and quickly. Insurance payers require timely filing and will often deny them based on time limits, so make sure you submit and resolve claims promptly and accurately.

Prevention of claims problems is a great first step in keeping your providers and their patients happy, but sometimes you have to go the extra mile. Betty Harder, owner of B. J’s Medical Billing Service in Portland, Michigan, describes an all-too-common situation in which she is forced to intervene:

“One of my clients had a patient whose claim was denied due to a missing Doctor’s Provider ID. I checked the claim in our medical billing software, and sure enough, the Provider ID was there, so I called the insurance company and pointed it out to them. They said that the claim must have been recently updated and resubmitted it.

Three weeks later, the claim was denied again, this time due to a missing Tax ID. After I called again and pointed out that the Tax ID was there, the claim was resubmitted, and once again the claim was denied after another delay, this time due to a missing doctor’s address. The address was there, too.

Finally, I got through again and pointed out that all of the denials were incorrect and that the original claim was clean. I demanded payment plus interest for the delays. We received payment in three days.”

Betty went to bat for her provider and their patient and finally won, despite an uphill battle for several weeks. Her determination, with a little help from her medical billing software, gave her the edge. This is what really good medical billers do and why they succeed despite today’s healthcare challenges.

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