Is there a crack in your pot of gold?

What happens if your crack looks like $20 or even $100 and it is dismissed only to find out later it was over $18,000?

There are several areas where a practice may be losing money and not even know it.  Each of these areas will be reviewed over the coming months including providing specific areas that should be monitored in the billing process.  In Revenue Cycle Management (RCM), it really is a cycle.  Setting it and forgetting it is not a wise decision.  RCM processes must be continually reviewed, checked against rules and regulations, adjustments made, and edits put in place to streamline the process while solving issues that arise from insurance company changes.  Once you solve the issues, you must still follow the cycle and check back to ensure the solution is still successful.

Denials are always part of the RCM cycle so much so an entire series could be dedicated to denials alone.  Denials are claims that have been sent to and accepted by the insurance company, processed, adjudicated and returned without any payment or patient responsibility.  Generally, though not always, the insurance company will return a reason for the denial.  However, that reason may not be correct, or it may not be the real issue causing the denial.  This is where the detective work starts.  And this is where the practice needs to monitor the process to ensure a wily leprechaun isn’t standing by to take advantage of the crack in your pot of gold.

Three key attributes to effectively resolving denials:

• Knowledge
• Persistence
• Patience

All three of these qualities are necessary to effectively overturn denials.

Knowledge

The knowledge and appropriate tools will allow an effective team to build successful leprechaun traps to prevent the loss of any gold.  The billing company or billing department must first and foremost have the knowledge of the coding rules and regulations.  It starts with applying the correct codes such as CPT, ICD10, HCPCS, etc., but quickly moves to the rules of the insurance companies as well as regulations set forth at the state and federal level.  While many insurance companies follow similar guidelines, they can set additional policies for coverage and allowable procedures.  The team processing denials must have knowledge of each insurance company’s policies.  The knowledge will be used to determine if the denial is accurate, what additional information may be needed to resolve the denial, identify if there are any trends to the denials returned and if possible, put in pre-edit checks to avoid the denial next time.

Persistence

In addition to knowledge, persistence is vital when denials flow through the RCM process.  Insurance companies deny claims for various reasons.  One of those reasons is when there is missing information.  This information may not be missing on the claim filed but may be missing from their records causing a denial.  There may be an information mismatch such as a date of birth is different on the claim compared to what is on file at the insurance company.  The insurance company may have requested information from another entity or the patient.  Without a response they are unable to process other claims, thus a denial is issued transferring the burden back to the physician who provided the service. In some cases, the insurance company denies the claim incorrectly due to a flag or edit in their system, a policy change or a contract may have been loaded into their adjudication system incorrectly.  These, in addition to others, requires the denial team to be persistent throughout the process until the claims are paid.  Timely, persistent, and documented follow up for each denial must be adhered to for the opportunity to resolve the denial and receive payment for the services rendered.  Irish folklore describes leprechauns as cunning and sly.  While just folklore, the lesson remains, to stop the mischief from continuing there must be a persistent effort to stop it.  The same holds true for denial processes.  One attempt will not always stop a trend, nor will one attempt catch the fabled leprechaun.  Persistence is key.

Patience

Although patience is not often associated with claim denials, it is a key element to resolving denials.  It is fairly simple to follow up on a claim from an initial denial.  It is also fairly simple to check back on it once or even twice.  However, whether the denial team is part of the billing department within the practice or at a billing service outside the practice, not many will continue the follow up for months to ensure the denial is resolved and the money is paid to the provider of service.  A leprechaun trap may take days, weeks, or months of monitoring before results are seen.  As with anything worthwhile, results are not always immediate.  To increase success rates, patience must be exercised.  To ensure the practice is reimbursed for all their services rendered, the denial team must continue working with the insurance company to resolve the denial.  In some cases, this means going the extra mile to walk the insurance company through their error, with logic, rules and regulations, and documentation to help them understand why the denial is incorrect and the provider should be reimbursed.

A denial example with a commercial insurance company

While it looked like a simple first in, first out claims payment process, it was not.  There are times when the insurance company will pay on the first claim that arrives and not the second.  It is a routine process to notify the insurance company of the correct provider of service and have the claims reprocessed and paid correctly.  However, in this case, they did not reprocess and even stopped responding to the appeals.  We were persistent with continued follow up to the insurance.  Our knowledge of the policies, rules and regulations allowed us to have a comprehensive understanding from the professional, technical, and referring physician claims processes.  We exercised our patience while the insurance reviewed the information on their end, after we provided the documentation necessary to prove the claims were payable to the provider of service.

After months of phone calls, emails and even conference calls with multiple parties, we were successful helping the insurance company to see their error, update their system and remit payment for all claims on this issue.  Throughout the process, we kept the practice updated on the status of the issue.  Over those months of persistence and patience, the insurance company underpaid by over $18,000. One might think that most denial teams would work on $18,000 worth of denied claims.  However, the claim denials were under an average of $20 each.  It is common for teams to skip over items that are $25, $50 or $100 dollars.  Had we taken that approach, not only would $18,000 have been lost, but the issue would still be happening today so the loss would continue to rise each day.  Instead, we sealed the leak in the pot of gold for the practice and we continue to monitor to ensure the leak does not reopen.

Knowledge.  Persistence.  Patience.  A successful denial team must have all three: the knowledge about the insurance company’s rules, persistence to ensure the denials are addressed with the insurance company and patience to monitor the reprocessing of the claim with the insurance, checking back at specific intervals to validate the claim is moving through the adjudication system for resolution and payment.  Monitor your billing process including denials!

Are you sure your denial team is watching your pot of gold to make sure all cracks are sealed?

Or are they watching only the big dollars and forgetting to watch ALL your dollars?