What are Your Rejections and Denials Trying to Tell You? Advice from RCM Expert Elizabeth Woodcock

How can medical practices and billing companies better understand their claim rejections and denials? How can they keep the same rejections and denials from happening repeatedly? These were two questions we posed to Revenue Cycle Management expert Elizabeth Woodcock, MBA, FACMPE, CPC, who will be conducting two webinars for Kareo on the topic of achieving clean claims in 2020.

Co-author of the bestselling book,The Physician Billing Process: Navigating Potholes on the Road to Getting Paid, Woodcock will be presenting, “How to Exceed a 95% Clean Claims Rate,”  on January 28  for independent practice physicians and their staff (register here). The webinar will address how insurance is changing, why payers have increasing incentive to deny claims, the root causes of rejections and denials, strategies for preventing denials, denial management processes and much more. 

In advance of the webinars, Woodcock was asked what advice she would give to independent practices and billing companies regarding achieving clean claims. She began with an explanation of the stages of the claims process. Problems with clean claims can occur as a charge is being entered – or when the insurance company adjudicates your claim months later. Accuracy upon entry is vital - preferably using electronic claims submission software, as it offers an opportunity to correct errors before submitting the claim.

The greatest challenge, Woodcock says, occurs when billers don’t use what they learn from these problems to prevent them from happening again. Yes, it takes a little more time to change the process, but it will save immense amounts of time later and improve the bottom line of the practice. She explains how:

  1. Run the reports. Run reports about errors, rejections and denials at least on a monthly or weekly basis. Some practices and billing companies run them daily. Study the reports and look for trends and consistent areas of challenge.
  2. Look for areas of opportunity. Each error or denial represents an opportunity to improve your process and boost your clean claims rate. These reports aren’t punishment or accusation. Woodcock says quite the contrary. They can be creative challenges for your entire group. For example, if you see a lot of “subscriber not eligible” on your reports, it’s a chance to look at your front-end process. If eligibility checks don't occur until until patients come into the office for their appointment – and this step often gets missed during a busy clinic – this report prompts a change to consider a new process. This may include having the scheduler leverage real time eligibility checks when the appointment is made. Changing this process takes some time and training but it could improve the chances of clean claims. Billing companies can help their clients understand what consistent problems are appearing and prompt a possible change of process.
  3. Don’t try to fix everything at once. At the beginning of each year, run the reports and identify perhaps four areas you want to improve that year. Tackle one a quarter. Implementing real change takes careful thought and a retooling of processes, as well as people and technology. Don’t overwhelm your staff. Analyze each area of change carefully and work on it until it’s running smoothly. For example, a practice might consider eligibility checks one quarter, then clearinghouse rejection codes, referrals/authorizations and finally, medical necessity. Or, if this seems too much to tackle all at once, break them down into subtasks.
  4. Do it right. Identify new processes that your team thinks will help solve the problem, and make sure the staff doublechecks that it is working.
  5. Engage the team. Share the reports. Get the team to identify the areas of change and suggest the steps to solve the problem. No one person has the full view. Then involve the team in the results, both successful and not, and include them in fine-tuning the steps needed to achieve success. Celebrate together.
  6. Be patient. Since the billing and payment process runs behind operations, don’t expect to see immediate results from your changes. Sixty to 90 days are typically needed to determine if rejection and denial management process improvements are achieving the results you want. It may take several more months to experience positive financial consequences.

With all the demands on independent practices and billing companies, it can be easy to just resolve a single denial and move on. But learning from those denials and using the knowledge to improve your processes is the way toward achieving a 95% clean claims rate, happier patients, less stressed staff and an improved bottom line this year and years to come.  Lastly, if you're interested in learning more strategies for successful denial follow-up, check out the blog in the link.

To learn more about what will put you on the path to claims success, sign up for Kareo’s January 28 webinar for independent practices on January 28 here.

About the Author

Cher Knebel is a Sr. Content Marketing Manager at Kareo and joined the company in 2019. She has been a content creator for more than two decades, specifically working...

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