How to Reduce Claim Denials for Independent Medical Practices?

Gone are the days when we had to walk up to the nearest hospitals and nursing homes to get ourselves and our friends and family treated. We now have independent medical practices working to improve the health conditions of the patients that save their loss of time and of money.

These practices work as an integrated healthcare unit that helps the patients get rid of their ailments in a journey that is a lot less time taking and hassle-free. In today's independent medical practices we have doctors/physicians who sit for the counseling of the patients and proceed with the diagnosis. Here, we have a wide range of specialties for the patients to choose from, which takes care of an array of illnesses.

The patients, who are now onboarded with the improved digital appointment schedulers, followed by paperless intake methods and instant, online check-ins that many practices now have been equipped with, are then billed for the services and even here, the practices are now largely adopting the digital billing process.

The billing process, claims, and insurance denials!

We are already aware that the practices that we have today are equipped with a range of functions and facilities that help the patients get all that they want when it comes to healthcare treatment. Digital is the way of the world and this is the reason why the practices are largely focusing on digitizing their systems and improving their workflows.

According to the survey, the market for the EHR/EMR software products has widely increased and is pegged to increase more in the upcoming years, which is currently estimated to reach around $38 bn in 2025. The massive drive for digital ways is something that can largely be credited with this boom in the growth of the EHR/EMR software that we are currently witnessing. Besides, telehealth and the need for it was never before realized if not for the outbreak of the global coronavirus pandemic.

The COVID-19 pandemic led to a situation, not only in the healthcare industry but also in all the other industries both big and small, where physical distances need to be kept and restrictions need to be upheld in the physical world. As a major part of restrictions was involved with the maintenance of social distancing in the physical world, the healthcare industry, along with the others, counted largely on the digital ways to improve its productivity, maintain its workflow, and keep the revenues coming, thereby lending a positive patient experience.

The digital software and systems that are introduced to the healthcare industry, have benefitted almost all of the existing processes in the practices. Among all other processes, the billing department was one of the foremost departments that needed a break from the regular analog practices. The billing department is a crucial department not only for the practices but for the healthcare industry in general. This is because it is the billing process that determines the revenues and calculates the same, based on which the annual income-expenditure ratio and more is calculated. Besides, billing errors are one of the biggest issues that the medical industry is batting with since times immemorial. Research says that over 13% of medical bills contain errors. Furthermore, it has also been seen that the bills that total $10,000 or more, consist of an average error that costs around $1,300, which is certainly woeful!

Billing is a process that is largely diversified and yet is a whole. This is why the billing department is so complex to understand and to carry out. Furthermore, with the billing process being a complicated one, it also has the ill-reputation of being a major factor that contributes towards lengthening the patient wait times. With an aim to improve the billing process in the practices of now, GrowPractice, one of the leading providers of medical office software, has now brought in effective practice and patient management software that includes improved billing software, which is integrated into the system. These medical office software and systems from GrowPractice would definitely help the medical and dental practices and urgent care clinics, to revamp their medical office and its services, thereby enhancing their revenues.

The billing process witnesses a whole bundle of issues. To list some of the prominent billing problems that the patients and the practices face are:

Insecure processes

Secure billing process is a crucial thing that needs to be pursued by all medical and dental practices. Around 78% of the patients have been discovered to be very particular about the security of the medical software and portals that they use, and around the same percentage of the patients would also want secure billing processes in practices. Therefore, the insecurity in billing is a primary thing that the practices need to address and they can easily do so by opting for the secure billing software and medical systems by GrowPractice.

Lengthen the patient wait times

The billing processes are not only complicated in nature but also time-taking as well. While most of the practices earlier used manual practices in billing, a large number of them also had to keep patients waiting, thereby increasing the wait times of the patients. Now, the patient wait times are a major deciding factor when it comes to the patient experiences in practices. As per recent records, 1 in every 5 patients has changed their providers due to long wait times. Therefore, in case you are wondering about reducing the patient wait times, then choosing Growpractice and its digital billing systems will certainly be rewarding.

Fails to address properly in times of rush

The healthcare industry is forever in an emergency, and this might even increase from time to time. The COVID-19 pandemic can be the latest example of how much of a rush the practices and the industry of healthcare can witness. Now, with the increase of patients, the practices also need to address the same and be quick in doing the same. Here, the billing process can come up as a major obstacle for the practices and how they can handle the patient rush. GrowPractice understands the medical exigencies which is why they are bringing in the most efficient billing process with the medical software for the practices to revamp their offices.

Loss of patient information

PHI or protected health information needs to be safeguarded as per the guidelines of the practices or the HIPAA guidelines. However, when it comes to the manual methods in practice, many patient-sensitive information might also stay at the risk of getting lost and/or misplaced. A huge amount of data has been reported to be lost even from the digital portals and software too, which is something that simply cannot go on. Therefore, to keep your medical data intact and always integrated with your medical office software, GrowPractice offers online patient intake forms that automatically update the patients' data into the EHR systems without bothering any other medical employees. Along with it, the leading medical office solutions provider, also extends improved billing process to get on fast with the bills and patient claims.

Witnesses numerous claim denials

Claim denials are a major issue when it comes to the billing process that independent medical practices and others often face. Many patients today have got themselves or their dear ones insured, which saves them from investing their capital every now and then for healthcare. Therefore, it is certainly disappointing when their insurance claims are denied. Health insurance denial is a major grievance that a large number of patients note. However, the exact reasons an insurance claim can be denied can be numerous and can vary from patient to patient or case to case.

Erroneous medical claims processing

The patients have also been tired of getting medical claims processed erroneously. As per the recent statistics, over 50% of medical claims contain errors, which makes up for more than half of the billing errors. These errors in the processing of medical claims can be many and varied, where the billing software also plays a central role. GrowPractice's cutting-edge billing processing software and systems can reinforce the medical offices of today with the best and the most effective billing software that will keep their medical bills and claims effective and error-free.

How and why are the patients' insurance claims denied in practices?

The billing process certainly sees a whole lot of issues and has to dodge them out every single day. One another issue that the billing process has witnessed to be increasing over time is the denial of medical claims. Along with faulty claims, the denial of claims is something that can severely annoy the patients and lead to poor patient satisfaction ratings for the practices.

Denied claims are prominent when it comes to medical claims processing but some claims can also be rejected!

Yes, there are two kinds of issues when it comes to medical claims:

Denied claims

Denied claims, as negative as they sound, are the medical claims that are processed by a healthcare representative, followed by another round of processing by the insurance provider, and finally turn out to be unpayable or denied payment. Some of these claims that are denied can be violating the patient-payer contract or may have some vital errors that were only discovered after processing. Denied claims cannot simply be resubmitted until the cause of their denial is determined.

Rejected claims

Rejected claims are another healthcare claims issue that the patients often witness when their claims are not denied but rejected instead. This rejection of the patient's insurance claims can be due to one or more errors found before the claims were processed. The medical claims that are rejected were the claims that were never entered into the computer systems because the data requirements of the claims were not satisfied fully. In a rejected claim, the errors that are there on the claim, will prevent the insurance company to pay for the claim and would instead reject it, thereby sending it back to the biller to be corrected. Once the rejected claims are corrected, they can again be submitted because these kinds of claims were never entered into the system due to the error persisting in them.

Denied claims are such medical claims that are received and processed not only by the biller but also by the payer, which were then deemed unpayable. The health insurance claim denials are usually reverted on an Explanation of Benefits or Electronic Remittance Advice (ERA). Denials of insurance claims of the patients would also have an explanation regarding why the claim was denied when it will be sent back to the biller. Such a piece of information would always be effective for the biller or practices, which normally process and send insurance claims to the payer or the insurance companies on behalf of the patients.

However, if you are wondering whether you can send the health insurance denied claims back for processing, then don't worry because you can certainly send the denied claims back to the payer or the insurance company. However, this process is almost always deemed to be costly and time-consuming as well, which negatively affects the patients and the practices as well. Thus, it is always regarded as a huge boon for the patients and practices if the claims are accepted right in the first attempt and even here, GrowPractice can largely come to the benefit of the healthcare practices and is already proving to reduce the patient claim denials by 15%.

Insurance companies denying claims can happen due to more than one reason. Here are some major reasons why the healthcare claims are being denied today:

Timely filing of claims

Timely filling of claims is essential to improve on the denial of healthcare claims of the patients. Each claim comes with a particularly appropriate time slot under which the claim needs to be filed in order to have it approved or processed. However, most often it is discovered that the providers neglect the time slots and delay the submission of the claims to be accepted by the payers, which evidently leads to the insurance companies denying claims.

Inaccurate insurance ID or number

The healthcare providers, who file out the insurance claims on behalf of the patients, also need to check the patient insurance ID/ insurance number before they proceed with the submission of the claims. Here, it is important that the practices are aware of the patient's information and this can be perfected with the use of digital medical software and tools and an effective patient intake process.

GrowPractice's accurate digital patient intake forms and online check-ins are fast, secure, and effective, which enable the providers to capture the patients' information effectively and automatically copy them to the integrated medical office software and systems, without much manual interference. These automatic updates that the GrowPractice software promises, help the practices fill the patient claims effectively.

Filling of the services that are not covered

The claims policy differs from one insurance provider to another. This means that the set of services covered by a particular payer is determined by the individual payer's policies. Here, firstly, the provider needs to conduct proper research as to whether a particular case is liable to be accepted for claims, and secondly, it is important that the healthcare provider keeps the insurance provider in the loop in every step. These will not only help the providers improve their claims denial rates but will also massively improve the patient experience in the long run.

Lapsed coverage

The insurance coverage of the patients needs to be renewed from time to time in order to help the patients get the most out of their insurance plans. However, it has been seen on numerous occasions that they fail to do so and this can easily be the reason why a particular patient's insurance claims are denied. The lapsed insurance coverage is also identified as one of the most common reasons why the patient's claims are being rejected/denied today. However, a patient care unit or practice can improve these denial rates by thoroughly investigating the patients' cases and checking for lapsed coverage, thereby giving them an edge to their billing ways.

Bundling of the services reported

The billing of the services plays a major role in influencing a particular patient's claims and when manual procedures are implemented, it has to be admitted that not all of the medical staff have the expertise or utilize their own time to properly research and then bill the patients. However, with the digital billing procedures that GrowPractice offers, the providers of now can bundle the claims properly. It has to be admitted that the providers and their healthcare staffs also need to be educated and informed enough to code or bill the service together only that can go together and bill all the other services separately. This is also what GrowPractice aims to improve with the help of the cutting-edge technology it is bringing with its medical office software.

Issues with the use of the modifiers

There exist several modifiers when it comes to the billing and insurance claiming process. Modifiers 25 and 59 are quite common here and indicate whether a particular service or procedure was done on the same day or on separate days. For example, modifier 25 is used for evaluation and management (E/M) services that were provided to the patients on the same day as another service. On the other hand, there is another modifier, termed as modifier 59, which stands for the procedures that took place on separate days. Furthermore, Modifier 59 also includes all the information regarding the services that catered to a different organ, a different provider, and are also used to indicate that a particular service is different from the typical routine of the original service.

Therefore, the providers always need to be alert and informed of the modifiers used because if these modifiers are used inaccurately, then it may also bring in claim denial issues. However, with experienced medical coding and billing experts to assist the billing department of the providers, the practices can count less on the errors and reduce insurance claim denials.

Incorrect modifiers have been discovered to be the reason for 61% of the initial medical billing denials and often lead to over 42% of the insurance claim denial write-offs.

Data inconsistency

Inconsistency of medical data is another obstacle that might hamper the processing of the patient claims, thereby resulting in health insurance denied claims for the patients and the providers. As already mentioned, the billing and claims department deals with tons of data, a tiny error in which can lead to huge issues, including the healthcare claims being denied for the patients.

Data inconsistency is something that can occur anytime, anywhere and with any provider, which is why it is important that the practices hire professional medical staff to operate their billing and claims desk and ensure the data entered there in each case, is true and error-free. GrowPractice's effective online medical office, billing systems, and software can stand by the medical practices to significantly improve the data inconsistency and enhance the positive processing of patient claims online.

Waiting period

The waiting period is something that is really common in the case of patient claims. Almost every healthcare plan has a waiting period attached to it and the patients and the practices should just stay aware of the same before they are processed. This waiting period given by the payers determines the non-coverage of certain pre-specified illnesses. Therefore, if the providers claim for these pre-specified patient illnesses that are not covered within the waiting period in that period itself, then that would just result in health insurance denials.

Non-reliable providers

Unjust practices and fraudulent operators are always there in the market to hamper productivity and lower customer satisfaction but it is the genuine providers that can change the impression of the customers. There are many medical insurance providers that simply deny claims to avoid the payment of the patient costs and thereby be in profit always but that's not how the industry should run. Therefore, it is always important that the patients choose a genuine and reliable insurance service provider, who will help them in their times of need.

Best tips for independent medical practices to effectively reduce insurance companies denying claims

The above-mentioned reasons are the most common ones that often contribute to denying the patient's claims. However, if you are still wondering about some easy tips to improve the claim denials, then here are some useful things that you may implement in your practice:

Improve the network

The network issues wreck havoc for the medical providers when it comes to medical claims and their denials. Increasing network issues often delay the filing of insurance claims for the patients and most importantly, can also contribute to health insurance denials. Therefore, improving the network issues and connecting to a fast and flawless network is the first step for a medical care unit if it is looking to improve the claim denials.

Hire professionals

Medical professionals are forever an asset to medical practice. Expert professionals are seasoned for specific departments and have an eye for the detail, which is thoroughly needed when it comes to the billing and insurance claims department. Hiring professionals have no alternative for the medical practices for sure!

Verify the patients' information doubly

The information of the patients needs to be properly captured and this can further be improved by doubly verifying with the patient's data. After the GrowPractice software automatically captures the patient data, it is the duty of the medical practices to go through it again in order to process the claims and bills satisfactorily. A proactive checking of the patients' data will certainly immune today's providers against the claim denials.

Implement advanced medical office software solutions

The advanced medical office software solutions offered by GrowPractice certainly help the practices improve the capturing and the processing of their data. This software is regularly updated and can be integrated with the other software in the medical office, which leads to the improvement of medical billing and claims processing.

Keep the patients informed

Along with improved tools and the latest digital facilities that the healthcare providers are now embracing, it is also important that the patients are kept informed regarding their claims processing. Thus, if the patients are informed, they can themselves check for the lapse of the insurance claims, the waiting period, or the services that are covered in it and help the providers proceed with their case effortlessly.

Stay clear of the deadlines

The deadlines always need to be maintained even in case of medical claims. There is a certain period within which a particular claim needs to be submitted, neglecting which can also land the patient and the practice in trouble. Submitting patient claims after the specified period is over will evidently deny the claim without any hopes of claiming the amount back for the patients again.

Revaluate the workings

Monitoring the practice workflow and the performance is solely significant for the practices. This needs to be monitored each day in order to help the practices improve all of its departments including the billing department, and the performance of its staff.

Catch the trends

You always need to be informed of the latest trends in bill processing and claim denials, especially if you are the owner or the manager of a practice. These trends help the practices gain important insights into the current claim denials and how they can be processed in a better way.

Manage denied claims

The insurance claim denials are a regular phenomenon but these denied claims can also be resubmitted by figuring out the flaws in them. Having effective claim denial management teams or experienced employees who are aware of the claiming process can certainly help the practices manage the denied claims effortlessly.

Choose GrowPractice and improve insurance denial rates now!

GrowPractice assures of quality and security with the matchless medical office software and solution that it brings to the practices of today. It is not streamlining the patient appointment bookings, reducing no-shows, cutting down the wait times, improving the rates of collections, streamlining the patients' journeys, and following them up properly, but also helping the patients get positive results when it comes to insurance claims.

The digital medical office solutions from GrowPractice enable the patients' to schedule, reschedule and cancel their appointments and also helps the practices to capture the patients' information correctly. Furthermore, the Growpractice systems ensure that the PHI is handled safely and is automatically updated to the EHR/PM software. This saves time, cuts costs, and improves the rate of claim denials, bringing in a positive patient experience and boosting the overall credibility and the practice revenues. Therefore, if you now want to avoid the insurance companies denying claims, then you can simply opt for GrowPractice now without thinking twice!