Introduction 

Hospital claim denials are becoming an increasingly problematic issue for providers, leading to financial and operational losses that can be hard to recover from.  Hospital claims must meet several criteria to be approved, ranging from technical accuracy and procedural correctness to timeliness. The impact of these denials can be significant. The providers are forced to spend time and resources correcting or appealing rejected claims instead of focusing on patient care. Hospital claim denials also require them to wait for reimbursement, leading to cash-flow problems and increasing A/R returns. 

Billions of dollars are lost in revenue by providers every year. Hospital executives must remain vigilant about identifying the causes of denial — such as coding errors or incorrect patient information — and mitigating the financial impact of these claims.  

There are actionable steps providers can take to help reduce or even prevent denials and ensure they are getting the reimbursement they deserve. 

Understand Insurance Policies and Billing Rules 

With a well-rounded understanding of insurance policies and billing rules, you’ll be able to identify potential issues and develop strategies for success that help your practice remain profitable. 

The first step to accessing insurance policy information is to review the insurer’s website. Most insurers post their policies and billing rules online. If you have questions or need clarification, contact your insurer’s representative directly.  

Common reasons for claim denials can be: 

1. Insurance policies and billing rules can vary by the insurer or even geographic region, making it difficult for providers to stay up to date on all the latest requirements 
2. They do not submit their claims in a timely manner. 
3. Providers can also be denied payment for Claims that do not meet insurers’ criteria for coverage. For example, an insurer may deny payment for a procedure that is not considered medically necessary or that is not covered by the patient’s policy. 
4. They may also be denied payment if they submit duplicate claims. 
5. They may also be denied payment if they fail to provide the insurer with accurate information about their patient services and procedures provided in accordance with the insurer’s guidelines. 

Keep Accurate Records and Documentation 

Providers should be cognizant of the types of documents necessary for filing insurance claims, such as medical notes, treatment plans, diagnostic images, lab results, medical device orders, and billing invoices. 

Having a complete and accurate record of treatment and billing information will help you appeal a denied claim or negotiate a settlement in case of an underpayment. 

1.  They need to ensure that they have correct codes for treatments, document all treatment plans, outcomes, procedures, diagnoses, medications, and services provided as well as accurate patient information. 
2. They should also make sure all documentation is easily accessible in the event of an audit or dispute. 

Utilize Software and EHR Systems 

1. Providers can save time and effort by using technology, such as EHR systems, to document patient health information. 
2. Can electronically send in bills and receive payments from insurance companies quickly. 
3. Improves accuracy when submitting billing and claims information. 

Quick tips to use technology in your favor: 

1. Should take the time to familiarize themselves with their systems, including any built-in error-checking features and regulatory compliance requirements. 
2. Must set up rules in their system for billing and claims processing for accuracy. 
3. Should use caution when entering data into their systems. 
4. Should take advantage of automatic alerts and AI technology for prompts that may help prevent errors. 
5. Providers should take advantage of online resources and tutorials to stay up-to-date on best practices and any changes in the industry and regulations. 
6. They should regularly review their system’s security settings and protocols. 
7. They should consider the importance of keeping a paper trail, whether it’s for billing or medical records, as well as archiving documents digitally when appropriate. 
8. Providers should use data analytics to track and monitor performance. 

Stay Compliant with Regulatory Requirements 

Here are some tips on how to stay compliant with regulations when it comes to billing: 

1. Understand HIPAA regulations: They need to understand the regulations set forth by HIPAA regarding patient privacy and security of medical records, as well as the rules about submitting claims and billing properly. 
2. Follow CMS regulations: They should also be aware of the regulations set forth by the Centers for Medicare & Medicaid Services (CMS) when it comes to claims and billing. 
3. Train staff: Must make sure that all staff members are up to date on the latest regulations, and that they understand the importance of compliance. 
4. Maintain security: Providers should make sure they have strong security measures in place to protect patient data. This includes implementing encryption and authentication methods, as well as regular assessments of systems and processes. 
5. Keep accurate records: Providers should keep detailed records of all claims and billing procedures to ensure accuracy and compliance with regulations. 
6. Monitor activity: They should also regularly review reports to identify any issues or discrepancies. 

Here at Apaana Healthcare, we understand the importance of helping providers avoid claim denials and strive to make sure that each provider has access to the most current information on payer policies, coding requirements, and more. To learn more about our services and how we can help you #avoidclaimsdenial, visit our website or call us at www.apaana.com  

Reference 

1. Advisory Board 2019 (Article)The State of Denials (advisory.com) 
2. American Hospital Association 2022 (Article) CMS data shows high rate of health plan claims denials | AHA News 
3. KFF 2022 (Report) Claims Denials and Appeals in ACA Marketplace Plans in 2020 | KFF 
4. CMS.gov (Research) Review Reason Codes and Statements | CMS 
5. CMS.gov (Report) Has Your Health Insurer Denied Payment for a Medical Service? You Have a Right to Appeal | CMS