Have you noticed your payers denying more claims lately? It’s not your imagination. According to the Advisory Board, payers are using more sophisticated technology to catch and flag claims for denial, including potential DRG downgrades and medical necessity issues. And many have begun adding their own criteria on top of those recommended by the CMS, often without notifying the provider. In response, providers need to step up their efforts to ensure the claims they submit are accurate, documentation complete, and submission done on time.
18% of in-network claims were denied by payers in 2017, with denial rates for some issuers reaching more than 40%.[2]
Timely filing is a significant—and mostly avoidable—cause of denials for hospitals and practices, and are among the most difficult to appeal.[3] And it’s no wonder since each payer can have multiple filing deadlines based on plan, state, contract, provider status, type of claims, etc.[4] Keeping up can be challenging, especially since deadlines can change at any time, going from years to just days. Considering appeals can take up to 90 days, not to mention requiring additional effort by your team, and it’s easy to understand the importance of meeting those deadlines.
Time is money. Once a claim is denied, providers have already lost 15 additional days in A/R.[5]
But to meet timely filing deadlines, providers have to understand each payer’s requirements and stay on top of changes. And that’s a problem, especially for providers already strapped with limited resources. The best way to meet deadlines is to have a buttoned-up claims management process. Not collecting complete information during the patient access process, inefficiencies in documentation and errors during claim submission can put a cog in the wheel that slows the entire process and puts meeting filing deadlines at risk from the start.
Following are six actions providers can take to reduce deadline-related denials.
Make sure patient information is accurate, including name, current address, and birthdates. Front-desk staff can sometimes be overwhelmed with a line of frustrated patients waiting to check-in, pay a bill, or ask questions. And this makes data entry errors more likely. It’s important that they understand the importance of accuracy and how a simple error can impact reimbursement. Submitting a claim with missing or inaccurate information is one of the top reasons for denials. Taking a lackadaisical approach to collecting patient information just adds to a backlog of denials and potential write-offs.
Verify coverage information for each patient encounter, prior to or at the time of service. This includes prior authorization requirements, medical necessity, and documentation needs, not just insurance coverage status. Verification software can automate and improve the accuracy of this process.
Ensure staff is up to date on codes. Simple errors in coding are a big problem, and ongoing staff education is necessary to achieve and maintain the proper level of accuracy. For hospitals or practices with high levels of staff turnover, this is especially important. Not only do shortfalls in this area lead to greater rejection rates, but they also slow the entire revenue cycle workflow, which can ultimately inhibit timely filing.
Often, a missed deadline occurs because a request for additional information is overlooked. When already overworked billers are struggling just to keep up with everyday tasks, these requests can slip through the cracks. By the time the deadline arrives, it’s too late. Staying on top of requests for additional information should be built into the billing workflow and considered just as important as other daily tasks.
Even after meeting the filing deadline, there will be times a payer denies the claim in error. It’s essential to have proof that the claim was submitted on time. Electronic submission makes this easy. On the other hand, if it was submitted as a paper claim, staff will need to gather the information from the practice management system or the hospital’s revenue cycle management systems.
Leverage analytics to determine opportunities for improvement. Using analytics software to identify problematic trends can help hospitals and practices identify systemic issues. By isolating payers that denied the most claims, staff can drill down to denial reasons. Those that deny the most claims for timely filing may indicate issues with contract compliance. Or it may indicate the payer has changed its deadline requirements, and the announcement was overlooked.
A different approach
As hospitals and practices struggle with decreasing reimbursements and increasing patient responsibility, they can’t afford inefficient processes that lead to increased denials and write-offs. For this reason, many providers choose to outsource the claims process to vendors with specific expertise—along with the appropriate technology—to streamline the revenue cycle on the provider’s behalf. The efficiencies gained can significantly lower costs and facilitate faster, more accurate payer reimbursements. Providers are relieved of having to keep up with each payer’s timely filing deadlines and subsequent denials, which enables staff to focus on more strategic tasks. With the right outsourcer, providers can experience a positive, quick, and ongoing return on investment.
[5] https://www.mgma.com/revenue-cycle/the-6-fundamentals-to-prevent-denials