The best way to minimize denials is to prevent them in the first place, by making sure that medical claims meet the requirements for clean claims. A clean claim is defined as a claim that meets the standards required by insurance carriers for payment on first submission.
The components of a clean claim include (but are not limited to) conducting accurate demographic and insurance registration of patients, meeting timely filing deadlines, performing insurance verification, complying with utilization-management requirements (such as preauthorization of advanced imaging), and reconciliation of incompatible diagnosis and procedure codes.
Registering the patient with the correct demographics involves gathering such patient information as his or her full name, correct address, date of birth, email address, and telephone number. This task is important not just in preventing a denial, but in ensuring that subsequent claims are filed for the correct patient.
The information collected at registration also is important in enabling the practice to reach the patient, should there be a need to do so. With the wrong demographic information, patients might not receive information on the status of their medical conditions, and they might not receive results from their medical exams. Without a current address, the practice will be unable to bill uninsured (self-pay) patients, resulting in potential revenue loss.
While accurate demographic information could prevent unnecessary denials, the implication of inaccurate registration goes far beyond lost revenue. In performing the registration task, the practice must maintain a consistent pattern of registration to minimize the possibility of duplicating a patient’s record. A practice might decide always to register patients with middle initials or to include the apartment number in a patient’s address, but whatever pattern the practice chooses, it is important to maintain consistency.
It is absolutely vital for a practice to verify the patient’s demographic information at every encounter. The verification process can be as simple as having the front-desk staff confirm a patient’s current address, telephone number, date of birth, and email address—or the process could involve having a preprinted form with the patient’s demographic information for the patient to confirm (or change, as necessary).
Making sure that the practice has pertinent insurance information necessary for claims payment is another strategy that can minimize denials. This process entails gathering the patient’s insurance information (subscriber number, group number, and effective/expiration dates). For patients with two insurance carriers, the information on the secondary insurance must also be gathered and entered into the billing system.
It is important for the registrar to designate the primary and secondary insurance carriers appropriately during the registration process (to prevent future claim denials due to coordination of benefits). The information on the primary and secondary carrier should be confirmed at every encounter to prevent claim denials, should the patient change or drop one of the two carriers.
Coordination-of-benefits denial occurs when a claim that should have been filed with a primary insurance carrier is filed with a secondary carrier instead. When a claim is denied for coordination of benefits, the practice must then determine which of the carriers is primary. This could involve something as minor as switching the insurance priority in the billing system, or it might require contacting the patient to find out which insurance is primary.
The insurance-registration process also requires the practice to identify a relationship between the patient and the subscriber (self, spouse, or parent/guardian) who is ultimately responsible for the medical bill. The identification of the relationship between a subscriber and the patient is important; it enables the practice to assign financial responsibility and follow up on unpaid claims.
Denial for late filing occurs when a claim is submitted after the expiration of the time allowed for submission. Insurance carriers generally designate the time period; for Medicare in New York, New York, it is 12 months from date of service, with managed-care carriers’ requirements ranging from 45 to 180 days.
Ideally, practices will submit their claims before filing deadlines, but denials for late filing could still