The Prime Minister’s recent voluntary national survey shed light on the Denied claims. The survey, conducted between October and December 2023, found that nearly 15% of all Medicare Advantage, Medicaid, Commercial and Managed Medicaid claims were denied. Between 45% and 60% of rejected cases were overturned, although the expensive appeals process sometimes meant multiple appeals.
When requests are denied, many doctors face financial burdens, leading to payment problems and hindering investment in medical device development. Additionally, hospitals and clinics are being closed in communities across the country due to this problem. Many physicians choose to invest in Revenue Cycle Management, but this article discusses why the manual approach can lead to financial problems.
Rejections can be avoided in 50% to 70% of cases with a professionally prepared appeal letter. In this article, we examine the basics of denials, the reasons why claims are rejected, and what needs to be done.
It is important to consider all possible reasons for Denied claims, including:
- Uninsured: The service or treatment may not be covered by an insurance policy for a variety of reasons, such as investigation, investigation, or exclusion. Due to certain political restrictions.
- Missing or incorrect information: Errors in patient information, physician information or service information in the application form may result in rejection.
- Failure to meet medical necessity: Some insurance policies require services or medication to meet medical necessity.
- Out-of-network doctors: Services provided by doctors outside the insurance company’s network may be denied or only partially provided.
- Prior Authorization Requirements: Services or treatments that require prior authorization must comply with the insurance company’s procedures; otherwise the claim may be rejected.
- Benefit reconciliation: If patients have more than one insurance policy, benefit reconciliation is required to process claims.
- Application Deadline: Claims must be submitted within the period specified by the insurance company; otherwise they may be rejected.
If the denied claims, the insurer must provide an explanation, including the specific reasons for the decision. In many cases, patients and health care providers have the right to appeal the denial by submitting additional information or documents to support the request. However, the negative explanation in the letter you receive is often vague and the person handling the complaint may not have the clinical expertise to effectively overturn it.
Here are three things to consider in your appeal process:
- Use medical practice and company guidelines and avoid over-reliance on personal information. Insurance companies care about whether something “meets the standards” of the software they’re not using.
- Understand the appeal process outlined in the commercial payer agreement and comment on whether the terms appear fair. Each provider makes their prices publicly available, but sometimes they also link to a small link on their website. Make sure your team reviews them and reads them carefully.
- Make sure the appellant and the RCM understand the original rights and inform them of any changes. The denial of prevention is the denial of what you don’t have to touch. A strong PA system is essential for a successful denial program.
It is essential to maintain a consistent process, implementation, monitoring and reporting. While it can be easy to become passive due to day-to-day work and deny this, it is an important component that affects financial health and outsourcing requires careful consideration. If your rejection rate is below 60% or not being followed up, consider hiring an expert to help you.
Why Allzone Management Services is the Perfect Choice for Your RCM Needs
Effective revenue cycle management (RCM) is essential for healthcare providers. Here’s how Allzone can help:
- Boost Revenue and Efficiency: Our expertise ensures accurate billing and coding, minimizes claim denials, and speeds up collections, leading to healthier finances for your practice.
- Reduce Administrative Burden: We handle the complexities of medical billing and insurance, freeing your staff to focus on what matters most – patient care.
- Improve Patient Experience: A smooth billing process keeps patients happy. Allzone simplifies the process and clarifies billing questions, leading to higher patient satisfaction.
- Stay Compliant: Healthcare regulations are constantly evolving. Our team of experts keeps you up-to-date and ensures your practice adheres to all coding and billing requirements.
- Optimize Operations: We identify areas for improvement in your revenue cycle, maximizing efficiency and minimizing costs for your practice.
Partner with Allzone and focus on what you do best – delivering exceptional patient care.
