Practical Guidance: The Most Common Reason Claims Are Denied

According to Daria Semanyshyn of Advanced Medical Practice Management in Florham Park, N.J., "the likelihood that your claim will be denied will probably be determined before the patient even walks through the door."

She says the most common reason for claim denials is poor preparation prior to the procedure. "An experienced billing company or billing department should know how to use modifiers, what claims forms to use for each carrier, how to correctly code your procedures and how to properly submit a form electronically," she says. "If your A/R is suffering because of these issues, then it is time to find new billers or a new billing company." Most often, she says, the reason for denials is not biller incompetence but rather lack of diligence in pre-operative verification processes.

She says before the patient arrives at the surgery center, your billing team should have verified the patient's enrollment and eligibility, coverage for certain procedures, pre-certification requirements and referral requirements. "Much of this comes down to the need for better pre-registration practices and better verification of benefits procedures," she says. "Once your patient has left your facility, getting correct and complete insurance information becomes very difficult. Likewise, attaining the necessary pre-cert or referral is near impossible."

She says a successful billing department will have standardized processes that each billing team member knows to follow prior to the date of surgery. Your ASC should establish how far in advance each task needs to be finished, then audit regularly to make sure your billing team is meeting these guidelines.

Learn more about Advanced Medical Practice Management.

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