Chandresh Shah

Practice Financial Analysis – Part 5 – Lower collections because of poor claim filings

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This week is a continuation of the high-level financial analysis of your practice.

Part of this analysis involves looking into your collections and related gross collection percentages. However, collections do not always meet expectations and there are a few possible reasons you should look for:

1. Shift in your payer mix (click here for last week’s article)

2. Decline in reimbursement rates

3. Poor follow-up on unpaid insurance receivables (Insurance A/R)

4. Poor front desk collections

5. Poor claim filings

6. Not sending out patient statements

7. Poor patient receivables management (Patient A/R)

8. Possible embezzlement


This week I will be focusing on the fifth reason : Poor Claim Filings.

It is extremely important to file clean claims, and this is a no-brainer and no surprises for anyone. Yet lower collection problems keep on pointing to initial claim filings not being very clean.

It is no surprise that rules surrounding medical necessity guidelines for various payers keep on changing. Medical practices must make adjustments to comply with the change. Because of these adjustments, billing staff must constantly stay on top of new guidelines. Business as usual will not work.

Proactive scanning of changes to the guidelines is most important. In spite of that, something can be overlooked and slipped. In those instances, following up on rejections can surface such changes to the guidelines which must be noted so that future errors can be avoided.

Below are top reasons to watch for to avoid rejections and denials of claim filings:

1.       Patient details.  This is one of the most fundamental things to keep in mind while filing a claim yet it continues to be 1 of the most common mistakes.

a.       Patient name spelled incorrectly

b.       Patient’s data birth on the claim does not match the data birth in the health insurance plan database

c.       Patient subscriber number is wrong

d.       Patient subscriber group number is wrong

2.       Checking for coverage eligibility of patient’s insurance. This must be done in 2 steps.

a.       The first and basic step is to make sure that the patient’s insurance coverage is active.

b.       The second is a more detailed check of determining if the specific services are powered or not.

3.       Prior authorization and precertification. Practices that provide services and procedures that are considered non-emergency may require prior authorization. Cases of this happening are more frequent than ever before. If services are provided without checking for prior authorization, your claims will be denied and it will be very difficult to get paid for them. Theoretically retro authorization is possible within a certain time period, but it is never recommended unless it is an absolute emergency and you have to provide the service without waiting to acquire prior authorization.

4.       Noncovered services. Many plans these days are basic, also known as bronze plans which exclude certain types of services. It is important to check this with the insurance before providing such services. If they are not covered, you must make sure that you inform the patient that they will be responsible for all charges. In these instances, the practice should attempt to collect and charge prior to providing the services. At the very least you should inform the patient prior to billing them.

5.       CPT or HCPCS codes.  Missing these code can will affect claims. It is up to the billing person to stay on top of these CPT or HCPCS codes changes.

6.       Timely filing. Billers must be aware of filing deadlines of each insurance carrier. In many instances, practices and providers insist that claims should only be sent after a note is signed. This practice is fine, except that it can delay submission of claims. It is my suggestion that providers should at the very minimum finalize the super bill and select the codes in order for the claim to be submitted in a timely manner. In no case, it should not be delayed more than a week from the date of service.

7.       Referral. Some services and procedures, require that a patient obtains referrals from their family physician prior to services being provided. These referrals must be on file prior to the services rendered. Obtaining a referral after the service can cause denials. It is very difficult to fight these.

Awareness and understanding of these reasons will help limit the rejections and denials to a minimum and decrease lower reimbursements due to common errors. Everyone in the practice can contribute to this- from the provider to the billing person to the front desk staff, as each can contribute to address lower collections because of poor filing.

138 thoughts on “Practice Financial Analysis – Part 5 – Lower collections because of poor claim filings”

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