Dealing With Denied Claims


Reimbursement constantly shifts in the healthcare industry. So far, the revenue year for medical systems and healthcare operators has not been particularly fruitful. Profits and stock prices for some leading industries have plummeted (read more), putting a tremendous strain on the healthcare staff and resources. At the same time, the number of medical claim denials has increased by 11% nationwide, affecting most healthcare establishments’ revenues. 

Based on research, there are several contributing factors to this issue. Some contributing factors include a lack of resources, backlogs, insufficient training, and outdated technology. Taken together, researchers say that staff education and training and the use of advanced technology may help cut denials, and in turn, a decline in lost revenue. 

The good news for hospitals, according to analysts, is that most claim denials are potentially avoidable! And the key to avoiding that is prevention. With that in mind, knowing the root cause may be the best solution to avoid hospital revenue loss.

What Is a Medical Claim?

This refers to a bill that a healthcare provider (e.g doctor) should submit to the patient’s insurance company documenting the services that the patient has received. This bill contains a list of medical codes that define any services that have been administered during patient visit, including the diagnosis. This is a step that is the first utilized before you actually receive the payment.

Making A Claim

Making medical claims to be reimbursed for the services you provide should be simple: provide the service(s), contact Lexington, make a claim, and receive service fees. 

However, not as straightforward as it seems, there are numerous potential pitfalls before getting revenue. The process may range from coding and data errors to claim edits made by your patients. And it can either be approved, rejected, or denied.

One factor to consider is the management of the claim process. Poor management can be a hindrance to the financial health of the establishment and to your practice. So avoiding denied claims should be one thing you should be mindful of. Learn more from:

  • Missing or Incorrect Coding Causes Delays!

In making a medical claim, it is important to note the frustrations you might encounter— especially on those small details that matter the most! Make sure to double-check the information you’re putting on the bill and ensure that they are detailed correctly. If not, this can cause delayed claims that may take a lot of your time. 

For the reimbursement, there has always been a time frame that is established for each patient. The period between the date of service and the filing deadline is usually 90 days, but it can be as short as 15 to 30 days in some cases. If you fail to submit a claim within the specified time frame, you will be forced to write off any associated charges. And the payers aren’t billed when a provider fails to submit the appropriate bill on time to the patient. 

  • Manual Coding

Human errors are inevitable, and by far, the most common reason for claim denials, fines, and revenue losses. These won’t just lead to high denial rates, but may also compromise patient care. 

In making a medical claim, several confusing codes can be frustrating to the healthcare staff. It will be difficult for you to get the payment from the payer unless all of the necessary documentation has been accurately collected.

But as mentioned, claim denials are often avoidable— especially with claim management software! 

Manual coding can be complex, but working with up-to-date software will not only provide you with real-time clean claims, it will also make it easier for you to spot coding errors that could lead to denials. See this Alpha II zero balance review about revenue intelligence platform. It’s critical to invest in software that provides the latest medical billing codes since they change frequently.

This can simplify complications, eliminate redundant procedures, and remove inefficiencies. At the same time, this relieves other health staff of administrative burdens, allowing them to devote more time to provide high-quality care. This, in turn, will make the rate of patient satisfaction higher. 

Patients who receive exceptional care and are satisfied with their healthcare experience are more likely to return to the hospital. In fact, according to a report, hospitals in the United States with an excellent patient experience had net margins that were 50% higher on average than those with a poor customer experience.