How even the most disciplined practices botch claim submissions and what they can do about it
Claims get rejected, and it doesn’t matter how thorough and experienced your billing staff is.
It still happens.
But practices themselves don’t always have personal responsibility for when the claim submission process fails. Even if they do everything right, practices will still encounter rejections from time to time, and, unfortunately, will still be on the hook to collect payment or face a loss in revenue. The reasons why this happens vary, and some of the most common examples are as follows:
Loss or revision of the patient’s insurance plan
If patients either lose or change their insurance plans, the claim will result in a rejection by the payer. This can be particularly tricky since this kind of rejection can even occur if practices do everything correctly on their ends. Patients aren’t always aware of any updates to their insurance that might affect the outcome of the claim, and might not be able to give providers adequate notice.
The problem can be exacerbated by payer response times. Insurance can take as long as 30 days to inform the practice the claim was rejected, narrowing the window to correct any problems and resubmit the claim.
Non-compliance with ICD-10 standards
Claims get rejected when diagnostic or procedural codes are either missing, incomplete, invalid, inconsistent, or do not correspond with the services provided in accordance with ICD-10 standards. This was a significant challenge for many practices during the ICD-10 compliance deadline of 2015, and even now for some it still is.
For some practices, the problem stems from conflating language in DSM-5 with ICD-10 standards. Because of the long-standing similarities between DSM-5 and the old ICD-9 standards, many industry veterans grew accustomed to thinking about billing through the lens of diagnostic language and not necessarily through the codes with which they were affiliated. It worked before when there was consistency, but there are real discrepancies now, particularly regarding PTSD and schizophrenia.
Check out Valant’s ICD-10 Crosswalk of the top 20 most commonly used diagnostic codes by clicking here.
The claim expired
When they are filed too long after the date of service, claims get rejected. For many insurance companies, the submission window is around 60-90 days. This may seem like a generous and predictable timeline, but where practices go wrong is failing to factor in the possibility of making corrections and resubmissions part-way through the claims process. Practices should always make every effort to file in a timely manner and keep the process moving as best they can.
Exceeded authorized sessions
Depending on the insurance provider and the nature of the services provided, there may be a pre-authorized limit of how many sessions will be covered. There may also be additional rules against providing more than one service of the same type per day. Any services provided outside the established insurance rules will run the risk of being non-covered.
The good news is a lot of risk can be mitigated by using technology as leverage. EHR software can be used to reduce human error and automate several aspects of the billing process. In particular, users can check patient eligibility electronically, track pending transactions, create fee schedules for the various providers at the practice, and in general standardize data and code entry, resulting in smoother, more efficient workflows and fewer rejections.
Even the best-intentioned practices will have their claims get rejected every so often, but those that can leverage EHR technology will have the highest rates of success and realize significant returns over time.