Wiki What is insurance claim denials and re-submission


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What are the best practices to reduce health insurance claim denials and resubmit / handle returned claims? I need to know about the process to help maximize claim approvals. Thanks.
Pray ;)

I would say it depends on what "tools" you have available to you. When I started I was seeing errors/denials on almost 5% of our claims. As I was posting the payment I would see the denial or error and immediately correct and resubmit the claim. Our software (eClinicalWorks) also allows me to assign the claim to me so I can track it and follow-up.

This was my bread-and-butter for a time but it bothered me that this was delaying revenue. Sure, we eventually get paid ... but it's extra work. Mom and dad were right ... it is less work to do something right the first time.

So I started looking for trends - a 25 modifier is constantly missed here (denial), the number of units is wrong here (error/underpayment), etc. I would still correct and resubmit the claim, but needed to address the root cause. It may be a matter of educating coders or providers ... or maybe they know but just "oops" sometimes. I opted to take it out of their hands. I was able to create custom claim edit rules. For example, if the claim has an E/M code and a nebulizer treatment but no modifer on the E/M - create an error and hold the claim. One by one I created rules to address the common errors I was seeing. There's now something like 20 rules and our claim denials are nearly zero. A denial for a coding error is rare. Using this feature allows me to stop the claim before it goes out, correct it, and send a clean claim.

I'd love to hear how others handle the process as well. This is what is working for us.