The average claim denial rate in the healthcare industry is between 5 and 10 percent, according to an American Medical Association’s (AMA) National Health Insurer Report Card (NHIRC) . Medicare and Anthem had the highest rate of claim decline in 2013. According to a report from the , more than 50 million Americans with chronic or persistent diseases were denied coverage by their health insurance. Almost two out of three patients denied coverage were denied multiple times and had to wait months for prescribed treatment. Almost 29% of those patients initially denied coverage reported that their condition worsened before they actually received treatment.
For these reasons, every claim that a medical billing and coding professional creates will need to be accurate and complete before it is sent to an insurance carrier, Medicare, Medicaid, TRICARE or worker’s compensation provider.
Guidelines for Claim Reviews Before Submitting
Every medical billing and coding professional should create a checklist to make sure a claim is accurate and complete before they submit it to an insurance carrier. Some important guidelines to list include getting proper signatures, proofreading the claim, making sure coding is accurate to the ICD-10-CM coding manual, confirming all patient information, obtaining the patient’s authorization to release information, the proper calculation of fees, the inclusion of the physician’s information, all attachments are added, and the original claim is forwarded to the insurance carrier.
Get Proper Signatures – make sure to follow office policy to get signatures for claim forms.
Proofread Your Claim – a medical billing and coding professional should always proofread a claim before it is submitted to an insurance company. The claim should be accurate and complete for it to be processed successfully. Make sure the diagnosis is not missing or incomplete.
ICD-10-CM – make sure the coding is accurate, according to the ICD-10-CM coding manual.
Confirm Patient Information – the medical billing and coding professional should compare the patient’s name, address, group and policy number to the insurance card. The patient’s birth date and gender should also match the medical records.
Authorized Release of Information – make sure the patient has authorized release of information, a handwritten signature or the statement “Signature on File.”
Properly Calculate Fees – fees for each charge must be listed individually. If more than 1 day is entered the fees must be calculated properly.
Get Physician’s Information – the physician’s signature must be on the form before it is submitted for a claim. The physician’s federal TIN, EIN or SSN should be double checked for accuracy. The physician’s NPI number should be entered and provider’s PIN with the qualifying number if applicable.
Include All Attachments – make sure to include all attachments that need to accompany the completed form.
Forward the Original Claim – don’t send a copy to the insurance carrier, make sure to send the original claim form.
Preventing Claim Denial
It is important for a medical billing and coding assistant to abide by insurance company, Medicare, Medicaid, TRICARE and worker’s compensation procedures and codes for submitting claims. Don’t always let a clearinghouse manage the accuracy and completeness of a claim to not delay treatment to a patient. Also, make sure you are using a computer software billing system that checks the claims for errors.
The two main reasons for denial of payment are technical errors and insurance policy coverage issues. Technical errors include incorrect or incomplete information, typing errors or mathematical errors. Insurance companies may deny a claim if the services are not covered by the insurance plan or it is considered a pre-existing condition that is not covered by the insurance payer.
What is a Pre-Existing Condition?
A pre-existing condition is a medical condition that started before a person’s health benefits went into effect. The Patient Protection and Affordable Care Act reformed pre-existing conditions for patients that had been uninsured previously. After 2014 pre-existing condition exclusions where prohibited in all health insurance plans.
Explanation of Benefits (EOB)
The reason for claim denial is listed on the explanation of benefits (EOB) for commercial carriers, the remittance advice (RA) for some commercial carriers and on Medicaid claims, and the explanation of Medicare benefits (EOMB) on Medicare claims. If the claim is complete and accurate it is called a “clean claim.” If inaccurate or incomplete and returned for more information or correction, it is called a “dirty claim.” If a claim is rejected and payment is not made for any denied reason it is a “rejected claim.” Claims can be rejected because on non-covered services, if the procedure is not medically necessary, the procedure is experimental, the claim is inaccurately coded, pre-existing conditions exist or ineligibility.
Sometimes the claim is denied because of policy issues. If this happens, the medical billing and coding assistant should contact the patient to discuss the issue. It is the patient’s responsibility to resolve dispute over non-payment to the insurance company.
Did the discussion of medical claims interest you? Are you interested in becoming a medical billing and coding professional? If you’re interested in numbers and organization, then the Medical Billing and Coding program at Meridian College is perfect for you! In addition to your classroom experiences, you will also complete a school externship for on-the-job training that will bring you further expertise. You’ll be supervised by a physician, nurse or health services professional and learn the billing and coding process from the working perspective.
Contact Meridian College today to learn more about becoming a medical billing and coding professional.