Not all of the factors that influence claims payment are within your control, but you can take steps to lessen at least some of the frustration and unnecessary expense associated with claims delays and denials. The American Association of Health Plans, the Healthcare Financial Management Association and the Specialty Society Insurance Coalition recently convened a committee representing health plans, physicians and hospitals to examine problems with claims processing and identify best practices. The strategies described in this article are based on information developed by that committee, which includes the American Academy of Family Physicians, American College of Obstetricians and Gynecologists, American Academy of Dermatology, Bethesda Healthcare System, Piedmont Hospital, Group Health Inc. and Health Alliance Plan.

Your improvement efforts should begin with a careful review of your practice’s current claims processing systems. Enlist your billing staff (or billing service) to provide you with some basic information about your practice’s claims processing performance. You’ll need the following information:

• The percentage of claims submitted within the last 30 days that were delayed,

• The percentage of claims submitted within the last 30 days that were denied on the first submission,

• The reasons most frequently given by payers for the delays and denials.

With the help of your office manager, use these data along with the best practices provided below to guide your improvement efforts.

Claims submitted to the wrong payer

If a high percentage of your denied claims are denied because they were submitted to the wrong payer, take the following steps:

• For new patients, collect information about insurance coverage when they book their first appointment to allow you ample time to process it. Ask patients to provide the following information about their spouse and dependents as well as themselves: Social Security number, birth date and group/policy numbers for each of their insurance providers, including Medicare and Medicaid.

• Make it a policy to copy patients’ insurance cards at their first visit to your office. If the patient has secondary coverage, copy the card for that policy as well.

• Upon each patient’s arrival at your office, review the insurance information you have on file and ask whether it’s current. If the patient makes changes, copy the patient’s insurance card again. Keep accurate records of all insurance information (current and previous) for use in claims follow-up, appeals, disputes or coordination-of-benefits issues.

Claims denied due to ineligibility

To reduce the number of claims denied due to ineligibility, confirm eligibility for every patient visit – prior to the visit, if possible. Have your staff note when eligibility was confirmed and whether it was accomplished by talking with a payer representative, by using the payer’s automated phone system or online.

Claims denied or delayed due to coordination-of-benefits issues

If your claims are being denied or delayed due to coordination-of-benefits issues, follow these steps:

• Ask all patients whether they have secondary or other insurance coverage. Gathering this information and using it when billing the insurance carriers can reduce the number of claims that are delayed pending coordination of benefits.

• Verify whether each payer listed in the patient’s file is the primary or secondary carrier. This can be accomplished when checking eligibility if you do so via “live” telephone contact. In some instances, if the payer is secondary, the person you talk with may be able to tell you which payer is primary. Here’s a rule of thumb for dependent children covered under more than one policy: The payer whose subscriber has the earlier birthday in the calendar year will be the primary.

• When submitting a claim to the secondary payer, send a copy of the Explanation of Benefits from the primary payer. If you don’t, the claim will probably be denied or delayed pending coordination of benefits.

Denied or delayed Medicare claims

To reduce the number of denied or delayed Medicare claims in your office, try these tips:

• Ask new patients age 65 or older (or current patients who’ve turned 65 since their last visit) to show you a copy of their Medicare and other insurance cards, and update your records as needed. Remember it is possible for a patient to have only Medicare Part A or Part B or to be ineligible for Medicare despite being 65 or older. It is also important to find out whether Medicare-eligible patients have group health insurance. Federal laws determine when Medicare is the primary or secondary payer.

• If Medicare is the primary payer, check to see if Medicare automatically “crosses over,” or sends claims to, the secondary or other payer. Many health plans pay Medicare for this service. If the patient’s claim is crossed over and you submit another claim directly to the secondary payer, the latter claim will be denied as a duplicate. The Explanation of Medicare Benefits should indicate when a claim has been crossed over for consideration by the secondary payer.

Claims denied as duplicates

If your practice is seeing a substantial number of claims being denied as duplicates, the following steps can help improve your billing process:

• Establish a minimum rebilling cycle of at least 30 days to allow time for the original claim to move through the payer’s cycle. Resubmitting a claim in less time uses unnecessary resources and is likely to result in the claim being denied as a duplicate.

• Reconcile claims denials and claims payments at least every 10 days, working through any electronic error and rejection reports in the process. This will help you to avoid common mistakes such as rebilling a denied claim or billing the patient’s portion to the insurance carrier.

• Don’t automatically rebill all outstanding claims. When a claim requires follow-up, your first step should be to contact the payer (by phone or online) for additional information.

Appeals or corrected claims denied as duplicates

To reduce the number of appeals or corrected claims being denied as duplicates, follow these steps:

• Be aware of the special requirements that each of your payers may have for submitting appeals or corrections. For example, some require that appeals be submitted on a specific form and not include a copy of the original claim.

• Unless the plan directs you otherwise, do not simply stamp a claim as “Second Request” or “Appeal.” Such claims will generally be treated as new claims and denied as duplicates.

• Be sure that the appeal or correction is submitted to the correct address. Many payers request that appeals be submitted to an address or post-office box that is different from the one used for original claims.

Claims denied due to missing or inaccurate information

If missing or inaccurate information is causing your claims to be denied, enact the following procedure:

• Double-check every claim for completeness and accuracy prior to sending it to the payer. Common billing errors include providing incorrect or incomplete patient information (e.g., member number, policy number, full name of subscriber) and incorrect or incomplete service information (e.g., date of service, diagnosis codes, CPT codes and modifiers).

The bottom line

By implementing these strategies, you’ll be able to shore up your accounts receivable and optimize your claims processing system. If your practice is like most family practices today, you can’t afford not to.