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    Welcome to the ClaimCare Medical Billing Blog. We strive to provide content that improves the overall quality of medical billing efforts across the US. If you have any specific topics that you would like to see addressed in this medical billing blog please post the topic in the Medical Billing Questions & Answers Forum. If you have an article that you would like considered for publication in the medical billing blog then please email your article to resources@claimcare.net.


    Rejected Medical Claims vs Denied Medical Claims: What's the Difference?

    Posted by Carl Mays on Tue, Sep 10, 2019 @ 03:20 PM

    Rejected Medical Claims vs Denied Medical Claims_ Whats the DifferenceLooking back, to look ahead: With ICD-11 on the horizon for 2022, Centers for Medicare & Medicaid Services (CMS) reported in 2015 that claims were processed with fewer rejected and denied claims after the transition from ICD-9 to ICD-10. Rejections and denials are projected to decrease even more when ICD-11 takes effect.

    Meanwhile, while dealing with ICD-10, many providers are confused on how to differentiate “rejected” medical claims from “denied” medical claims. This article discusses how you can distinguish the two from one another and steps on how to avoid both.

    What are rejected medical claims?

    These medical claims are considered unpayable and are sent back by the payer due to:

    • Incorrect information
    • Failure to meet specific data requirements
    • Non-adherence to the required formatting

    Due to these reasons, rejected medical claims are not even entered into the computer systems of payers. Thus, they cannot be processed.

    Once the error has been fixed, rejected claims can be submitted for approval. Thus, it is important for your medical biller to properly code and complete the information required by the payer.

    How are denied medical claims different from rejected medical claims?

    Unlike rejected medical claims, denied claims have been received and processed by the payer, but considered unpayable. Although these claims can be resubmitted, it should be done with a reconsideration request or appropriate appeal. Otherwise, it will just be denied once again costing your practice or facility more time and money.

    What causes a medical claim to be denied?

    Several factors can result in a denied medical claim. This includes:

    • Incorrect patient identifier information
    • Termination of medical insurance coverage
    • Requirement of prior authorization or precertification
    • Excluded or non-covered services
    • Requires supplementary medical records
    • Auto or work-related incident
    • Invalid CPT or HCPCS codes
    • Lapse of the filing date
    • Lack of referral on file

    Thus, make sure your medical billers and coders are knowledgeable regarding the latest medical coding updates and are skilled in properly preparing your medical claims. Otherwise, you’ll have instances of medical claims being denied and rejected by the payers.

    How can you improve your practice’s claim rejections and denial rates?

    There are several ways to improve your claim rejections and denial rates:

    1. Analyze and track your payer denial and rejection trends

    Review the most common types of mistakes and coding errors committed by your medical billing team. Create routine chart audits for documentation and data quality. Based on this information, create a course of action that will minimize, if not eliminate, these errors.

    2. Educating your medical billing and coding staff

    Invest in training your staff. Provide training on how to handle claim denials and rejections appropriately.

    Otherwise, consider outsourcing your medical billing to an “Experienced” and ”Knowledgeable” medical billing company. In this manner, you are guaranteed that the team handling your medical billing is well equipped, skilled, and knowledgeable in completing these tasks.

    3. Discuss your concerns with payers

    Schedule an appointment with your payers. Discuss, revise, or eliminate contract requirements resulting in denied claims, which eventually get overturned after an appeal. This helps to clarify the requirements in order to avoid future medical claim rejections.

    Are you having problems with your medical claim submissions? Do you need help processing these claims? Subscribe to our blog for more tips and updates.

    About ClaimCare

    ClaimCare has more than 25 years of experience in providing medical billing and coding services to various practices. Throughout these years, they have helped numerous organizations increase their revenue cycle by eliminating medical claim rejections and denials. Complete our online form or call us toll-free at (855) 376-7631 to learn more about the services we deliver.

    Tags: medical billing, medical billing services, medical billing resources, clean claims

    What Payers Don't Want You To Know About Clean Claim Laws

    Posted by Link Grader on Tue, Dec 30, 2008 @ 12:57 AM

    medical billing clean claim law Each state has passed a Clean Claim Law. The level of benefit these laws provide to medical practices and facilities starts on the low end with states such as South Dakota that provide little more than a slap on the insurance company's wrist to states such as Texas which levy substantial financial penalties on tardy payers.

    The basic idea of the law is that a payer has to respond to a clean claim within a set time (usually around 30 days for electronic claims). In order to utilize the clean claim law effectively you must have a tracking system built into your medical billing process that flags:

    • To which insurance companies does your state's clean claim law apply (some payers are exempt);
    • The date your practice initially submits each medical claim;
    • Events that stop the clean claim clock (e.g., an information request from the payer),
    • When your practice has taken actions in response to payer requests;
    • The date when you received the payer's final adjudication decision.

    The idea of systematically tracking all of this information may be daunting, but with a smart system design it is possible and most definitely a worthwhile undertaking. After submitting a few Clean Claim law violation reports you will see your claims pay faster. I have seen situations where payers have actually called just to assure the practice that claims will be quickly processed.

    One way to quickly get started using the clean claim law is to run a trial on a payer that you feel consistently takes more than 30 days to ajudicates claims. Find a small number of large claims for this payer that have gone past 30 days and then conduct a trial run with those claims. This will allow you to learn the fundamentals of how to submit and monitor complaints and see the results of your complaints.

    Copyright 2006 by ClaimCare Medical Billing Services

    Tags: medical billing, denial management, medical billing resources, clean claims

    Medical Billing Services Must Utilize Scrubbers

    Posted by ClaimCare Resources on Wed, Sep 17, 2008 @ 08:27 PM

    One of the most important things in billing is to create and follow a very structured plan that can be measured each step of the way. Remember, if it cannot be measured and monitored it cannot be improved!

    Clean claim submission can reduce average days in AR to less than 45 days

    claim scrubbingThe leading medical billing services operations utilize scrubbers that ensure your claims are clean before they are submitted to payers. These scrubs accelerate the speed of collections by avoiding denials and delays. They also increase collections by minimizing the volume of "re-work" and allowing billing staff to focus their efforts on pursuing true collections improvement opportunities and not simply resubmitting claims that should have been paid the first time. As a result of these scrubbers, over 90% of claims submitted are paid upon first submission. These "scrubbers" include:

    • Basic mechanical scrubber that assures that all claim fields have been properly filled with formatted data (social security number with 9 digits, date of birth etc), the NPI is in a proper field, there is a referring physician if needed, etc.
    • Scrubber that checks coding, bundling, and procedure information versus local Medicare and CCI rules. This scrub assures better coding, identifies overlooked procedures or codes.

    The truly great medical billing specialists can rely on medical billing specific know-how and business intelligence created over time through work with many medical practices and facilities in the given payer relevant geographic area.

    • Dynamic Proprietary Rule scrubber that checks for optimal coding and documentation versus the particular payer or plan's rules. This scrub assures that each claim is optimized for clean submission. When the payer or plan's rules change or when the billing office detects a systemic issue they can update the scrubber to filter and fix problems before claims go out. These specialized scrubbers can make a significant collections difference.

    At ClaimCare Medical Billing Services we have found that these actions can decrease the medical practice's collections cycle by up to 40-50 days. This is why you need to insure this critical step is being completed no matter who is doing your Medical Billing.

    Copyright 2008 by Carl Mays II

    Tags: medical billing services, scrubbing, clean claims

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