Reducing physician claim denials


Most practices have the software available that should enable them to produce and analyze reports which will provide valuable information.   By reviewing this information, you are able to see denial trends and provide educational feedback to the individual areas needed.  A new process may need to be implemented in order to prevent these denials from trending again.  Once the new processes are in place, it is important to monitor for improvements needed and if the changes are being implemented appropriately.   There are a few examples listed below that would be a great start to lower denials within your practice.

1. Referring and Ordering Physician incorrect or missing from charges, first thing is to be aware of payer guidelines and any changes that may have occurred.  As you know payer guidelines change often and without warning.  Here are a few things to keep in mind regarding referring and ordering physician requirements that are simple but will slip by.

 o Provider types that are not credentialed to order and/or refer for example an Audiologist or Chiropractor.  

o Be aware of services that require an ordering and/or referring physician missing from charge for example DME, radiology, laboratory and drug charges.

2. Many times Medicare beneficiaries are enrolled in a Medicare Replacement plan, instead of traditional Medicare.  By preventing claims from filing erroneously to Medicare instead of a Medicare Replacement Plan you can prevent extra cost of having to resubmit claims and in turn this will bring in revenue more timely.  Regardless of the carrier submitting claim to the correct payer initially is important.

3. Another denial that should be mentioned is duplicate claim denials, if more than one claim is submitted for the same member, item or service, date of service and provider the second claim will be denied as duplicate.  This can occur even if the original claim is in processing status awaiting payment.  If you resubmit a claim prior to receiving a determination from a carrier you increase risk of payment being held up.

When claims are submitted multiple times for the same service this may cause a claim to be suspended in the carriers system requiring need for human intervention there in causing revenue to slow down.  Some of these issues may appear to be low revenue but once you have a claim out the door you will have cost your business more by resubmitting corrected claim.   For an example, a low drug charge denies because the referring physician is missing with all remaining charges paid on claim it would not be cost effective to resubmit with this low charge amount.  However, if you prevent this denial from ever occurring at the end of the year those lower charge amounts could add up to substantial revenue. 

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