Claims can be delayed or interrupted at any place in its lifecycle. For many organizations, this is unnoticed – the claims fall into a ‘black hole.’ However, with quality controls and accurate reporting tools, this issue can be remedied. The impact of rebilling claims, such as duplicate denials or rejections, are typically are the root causes of increased cost and lost revenue.
Organizations with a complex payer mix such as Medicaid, Medicare, managed care and commercial can benefit from learning the denial matrix and cross-mapping used by each payer to avoid denials and duplications of claims. It is also advantageous for the A/R staff to be trained on the appropriateness of effectively rebilling claims, and the timeframe it takes to resolve them. Claims rejected by the clearing house are mailed to the address on the claim. If the address is incorrect, the claim is returned to the sender as undeliverable mail. Incorrect claim submissions, electronic or paper, is costly to an organization in such areas as claims, mailing/returned mail, and FTE working denial /reject backlogs. If a claim continues to be denied after several submissions, it can fall into the bucket of lost revenue due to missing filing deadlines.
There are several reasons that a claim could be denied. They include but are not limited to:
- Demographic –missing or invalid information
- Provider credentialing/provider enrollment
- System changes or updates –system updates should be made on schedule
- Missing authorization/referrals
- Missing/invalid information on the claim such as procedure codes, diagnosis, or modifier
- Timely filing – the claim was not submitted within the timeframe of the policy
To accurately re-bill a claim, the biller must be sufficiently trained and have the appropriate tools and resources to be able to determine why a claim did not clear. If your claim is denied by the payer or rejected by the clearinghouse, it is vital to find out why, regardless of whether it was submitted electronically or by paper. Become your own advocate in getting your claim resubmitted. It is not enough to simply request your claim to be resubmitted for reimbursement – you will receive the same result. Instead, contact the insurance provider to find out what information is needed to process the claim. Perhaps the issue can be resolved online by accessing the payer website or by updating or modifying internal controls and applications. Increasingly, payers prefer online follow-up processing instead of a manual process. Once information is received and updated in all the appropriate systems, the claim can continue through the process.
The claims processing cycle can be halted during different levels of the cycle. For example: 1) the system could cause delays or denials if the billing software applications are not functioning properly; 2) rejections can be made by the clearinghouse that requires research and investigation to the cross over malfunction to the payer; 3) the insurance information gathered at the time of registration is not accurate for primary, and secondary coverage; 4) there may have been an error in charge entry. If accurate information is entered at charge entry, the claim has a good chance of clearing the system clean whether it is submitted electronically or by paper.
The claims lifecycle is a long and winding path, with many areas for error. The staff is busy, and need to get their part of it done quickly. There is also high turnover in many of the related departments. Process and procedures go a long way to help ensure that claims are clean, and do not have to go the costly route of rebilling.