Playing Hide and Seek with Your Claim Denials

Posted by Madhu Singh on Thu, Jul 18, 2019 @ 11:07 AM

Many ODs may notice their claims aren’t being reimbursed, and in many cases they don’t have the bandwidth to investigate or they don't know where to start in order to figure out what went wrong. For someone who doesn’t handle the billing process on a daily basis, fixing denials can be a daunting task.

However, if you have defined your processes, it’s just a matter of reviewing each of them to find out where it has broken down. For practices who don’t have a system in place for managing claims, an in-house biller might be the most obvious solution.

We want to examine the processes at a typical office and review the biggest mistakes that could be made at the following stages:

  1. The OD Performs the Service
  2. The Front Staff Invoices the Patient for the Services
  3. A Biller Files the Claim
  4. The Clearinghouse Scrubs the Claim
  5. The Payer Accepts or Rejects the Claim
  6. The Payer Produces an EOB/ERA
  7. The Payment is Posted into Your PM System

Avoid These Inefficiencies in Every Step of Your Billing

Insurance Claims Medicare Blog ImageThe OD Performs the Service

Did you finalize the chart in your EHR prior to the patient checking out at the front desk/optical? If not, some services may have been missed when the invoice was created. Many EHRs push the data to the invoice for the front desk to use when checking the patient out. But, it only occurs if the chart has been finalized prior to the invoice being created. 

The Front Staff Invoices the Patient for the Services

Did your staff select the proper insurances and allocate the financial responsibility correctly when creating the invoice? Take 10 random invoices and verify that they were generated correctly.

The Biller Files the Claim

Are they uploading claims to the clearinghouse on a regular basis? You can check this by looking at the reporting in your clearinghouse. You can also tell by looking in the claims section of most practice management systems to ensure the data is being exported. This transparency is one of the big values of having a clearinghouse in the first place. We highly recommend leveraging the expertise of a clearinghouse. Avoiding this technology due to expense is penny wise but pound foolish. The typical practice will pay less than $100 a month for a clearinghouse. Correctly resubmitting just 1 or 2 claims a month will pay for this service.

The Clearinghouse Scrubs the Claims

Claims that do not meet the criteria set by the clearinghouse will get rejected. In the insurance company’s eyes, these claims were never filed. Is your biller addressing these rejections or are they sitting around gathering dust?

The Payer Produces an EOB/ERA

There will be rejections, denials, and payments reflected in these documents. Concentrate on the rejections and denials; is someone addressing these claims properly?

The Payment is Posted into Your PM System

If your payments aren’t getting posted on a regular basis, your PM system will reflect they are outstanding when everything is fine. There are many ramifications of poorly posted payments. Incorrect patient statements, forecasting future revenue, and denial management are all dependent on payments being posted properly.

Make sure you’re hiring an experienced biller, utilizing a clearinghouse platform, or outsourcing your billing to a team of experts. Within a few months, you should notice fewer mistakes throughout your claim process, experience a lower denial rate, and you’ll have more bandwidth to focus on your patients.


For our full list of common denials reasons, read our quick ebook online.

Get Your Guide to Common Claim Filing Denials

Tags: Electronic Claim Filing, Revenue Cycle Management

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