Successful Insurance Claims Submission & Reimbursement

adminTips

By Ranadene Tapio, MBA, CMRS, CPCS 

Does your office experience a rejection rate in insurance denials that’s higher than you’d like it to be? 

Does your front-desk and billing staff know the type of information that’s important to obtain when registering a patient? Do they know WHY the information they’re collecting is important? 

We have found, that the first step in decreased denials is employee understanding! If the employees that are registering your patients – or processing your claims – don’t know the significance of the information they are working with, chances of errors increase dramatically. 

Paying attention to detail is crucial to effectively process “clean claims”! Remember, “garbage in IS garbage out”.  

Clean claims are those that contain all of the correct information necessary to process the claim for accurate payment the first time. The most common data-entry errors – and lack of knowledge areas – that we’ve come across include: 

  • Insured Information. Often times when we help an office audit their denials, this is one of the major problem areas we find. If the information is not right in front of them, most employees will automatically assume that the insured is “same as patient”. If they don’t know that for sure – have them take the time on the front-end to make sure. A simple question by the staff can eliminate this problem. “Who is the policy holder for your insurance?” will elicit the response you need. This alone can save significant time related to denials of “patient not found” or “insured not found”. The insured is the person who carriers the insurance policy. At minimum, the information you need on the insured is their full name, birthday, and relationship to the patient. 
  • Patient ID Numbers, Birthdays, Etc. Make sure your employees are clear on the information that they’re entering. Is that a 4 or a 9? An S or a 5? An L or a 1? If they’re not sure – make sure you have processes in place that allows them to confirm the information. A denial for “ID number not on file” is very common, and usually is just a simple data-entry error. With all the data, numbers and logos that are crammed onto insurance cards, the information keeps getting smaller. A best practice is to use features like scanning the insurance card to auto-populate the information into your EMR/billing system, and/or using the scanned image capabilities to “blow up” the insurance cards until it can be read legibly. This will reduce errors due to misreading numbers. 
  • CPT, HCPCS & ICD10 Codes. Read and stay current with the procedure and diagnosis codes that are relevant to your practice and specialty. Doing this ensures accurate coding and billing, and that mismatches between CPT & ICD10 codes are avoided. For example, you can’t use a hysterectomy CPT code with a male diagnosis code. Similarly, you can’t use a vasectomy CPT code with a female diagnosis code. They won’t “match” throughout the various systems, hitting both frontend edits, and backend edits that make the claim reject. Therefore, it’s best to review coding prior to submitting the claim. 
  • Modifiers. Do you provide extended services to some of your patients? Do you perform more than one distinct service on a single visit? Make sure you’re versed in the use of modifiers – and use them as appropriate! 
  • Referring Providers. Do the primary services you provide in your office rely on the referral of other healthcare providers? Do you have a system in place that ensures you’re obtaining that providers name and NPI number with every new referral your office receives? The lack of (or incorrect) referring provider number is another common reason for denied claims. If you don’t already – make sure asking for this information is part of accepting referrals from other providers and/or part of a patient’s initial setup paperwork. 
  • Place of Service (POS) Codes. We all know that office visits use a POS 11, therefore most of us in a clinical office setting, default all of our CPT codes to bill this POS. But does your office also provide nursing home visits? Or in-patient hospital rounds? Or telehealth visits? Are you able to default the POS on your CPT codes based on the location you choose? If you choose location “office” will your system automatically populate the POS to 11? And if you choose location “hospital” will your system automatically fill in POS 21? Best practices suggest looking into the backend setup of your EMR system, to appropriate default as much as you can based on CPT code being used, in combination with which location is selected. 
  • Type of Service (TOS) Codes. Again, most of us in the clinical office setting, default our CPT codes to bill a TOS 01 (medical). But do you also provide DME equipment? Or Home Health Services? Are you making sure the TOS codes are either setup to default per location chosen or manually changing them on each of those claims? 
  • Provider NPI Numbers. This information should be defaulted into your system as well. Make sure you have each provider in your practice setup correctly and that all information tied to the provider file is accurate. 

If the claim lacks the information, it can make it harder for the carrier to find the patient or provider in their system. Don’t leave it up to the carrier to determine what you “mean” – make sure your claim is complete – and accurate! As the saying goes, make sure to “dot all the I’s and cross all the T’s”. 

The above-outlined errors will affect your overall denial rate. If the information you submit on the original claim is incorrect, the claim will be denied. You’ll then need to figure out why it was denied and work that denial. You must then determine if you can simply send in a corrected claim – or if you must take it a step further and request an adjustment or an appeal of the claim. 

All of these scenarios take up precious time. More time to work the claim, thus increased employee expense. More time to actually get paid on that claim thus decreased cash flow. 

You should also know your carrier contracts and fight for the dollars you deserve! Stay on top of CPT and ICD10 guidelines and know when to call a carrier regarding errors – bundling, timely filing, non-covered services, and a host of other denials can successfully be reprocessed or appealed. Persistence is key, so stay on top of your A/R. We have found that the more the carriers hear from us, the more we’re taken seriously. 

Ultimately, you can – and should – involve your patients and hold them accountable for their responsibility in knowing their benefits. Get them involved for those hard to deal with carriers. Sometimes that’s all it takes. We’ve found that carriers do not like unhappy patients/insureds. 


Ranadene (Randi) Tapio, MBA, CMRS, CPCS is the Founder and CEO MedCycle Solutions, which provides Revenue Cycle Management, Credentialing, Outsourced Coding, and Consulting Services to a number of healthcare providers in a variety of specialties. To find out more about MedCycle Solutions services please visit www.MedCycleSolutions.com.  You can reach Randi via email at Randi@MedCycleSolutions.com or call 320-290-6448.